Insertion system for deploying a ventilation device

ABSTRACT

An insertion system includes a handle assembly and a nose assembly removably attached to the handle assembly and including an insertion end. The handle assembly includes a main body, a nose interface and an actuating element. The nose assembly includes a nose, a positioning rod extending from the nose to a distal end, a cutting sheath surrounding a distal end of the positioning rod and including a cutting edge, an actuation member having a proximal end coupled to the actuating element when the nose assembly is attached to the handle assembly and a distal end attached to the cutting sheath, a ventilation tube positioned distal to the distal end of the positioning rod and proximal to the insertion end. The cutting sheath retracts from around the ventilation tube and along the positioning rod when the actuating element on the handle assembly is moved.

CROSS-REFERENCE TO RELATED APPLICATION

The present application is a divisional of and claims priority to U.S.patent application Ser. No. 13/826,497, filed Mar. 14, 2013, which isbased on and claims the benefit of U.S. provisional patent applicationSer. No. 61/660,280, filed Jun. 15, 2012, the contents of which arehereby incorporated by reference in their entireties.

BACKGROUND

Placement of middle ear ventilation tubes in the tympanic membrane is acommon pediatric surgical procedure for the treatment of middle earinfection or otitis media. Also known as tympanostomy tubes or pressureequalizing (PE) tubes, the procedure involves creating an incision(i.e., a myringotomy) in the tympanic membrane and placing a tube in theincision to allow ventilation, pressure equalization and drainage fromthe middle ear out through the ear canal. The tube can remain in the earfor months or years.

A tube is placed in the tympanic membrane via visualization through amicroscope. A sharp blade is used to create the incision and varioussurgical instruments are used to manipulate the tube into the incision.In the confined space of the ear canal, placement of the tube can bedifficult, especially in aligning the flange at one end of the tube withthe incision and the need for multiple different surgical instruments toperform the procedure. It is also not uncommon for the tube to dislodgefrom the surgical instrument or for it to accidentally extract from thetympanic membrane before being fully seated, requiring multiple attemptsbefore successful placement is achieved. In addition, the largeretention flanges included in most tubes make them difficult to maneuverin the ear canal and will actually block the clinician's view of theincision site.

Because the middle ear is highly innervated, repeated manipulation ofthe tympanic membrane is painful enough that patients, especially youngchildren, who make up the majority of tube recipients, require generalanesthesia. Such a drug therapy is costly and poses additional risks.

The discussion above is merely provided for general backgroundinformation and is not intended to be used as an aid in determining thescope of the claimed subject matter.

SUMMARY

An insertion system includes a handle assembly and a nose assembly. Thehandle assembly includes a main body, a nose interface and an actuatingelement that moves from a first position to a second position. The noseassembly is removably attached to the handle assembly and having aninsertion end. The nose assembly includes a nose, a positioning rodextending from the nose to a distal end, a cutting sheath surrounding adistal end of the positioning rod and including a cutting edge, anactuation member having a proximal end coupled to the actuating elementwhen the nose assembly is attached to the handle assembly and a distalend attached to the cutting sheath, a ventilation tube located distal tothe distal end of the positioning rod and proximal to the insertion end.The cutting sheath retracts from around the ventilation tube and alongthe positioning rod when the actuating element on the handle assembly ismoved from the first position to the second position.

A method of maintaining an opening in a membrane of the body includesassembling the nose on the nose assembly to the nose interface on themain body of the handle assembly. The ventilation tube is loaded intothe cutting sheath such that the ventilation tube is distal to thedistal end of the positioning rod and proximal insertion end. Theinsertion end of the nose assembly is advanced into the body so that thecutting edge pierces the membrane and the ventilation tube is locatedacross the membrane. The actuating element is rotated from a firstposition to a second position to retract the cutting sheath from aroundthe ventilation tube and along the positioning rod. The insertion end isremoved from the body.

This Summary is provided to introduce a selection of concepts in asimplified form that are further described below in the DetailedDescription. This Summary is not intended to identify key features oressential features of the claimed subject matter, nor is it intended tobe used as an aid in determining the scope of the claimed subjectmatter. The claimed subject matter is not limited to implementationsthat solve any or all disadvantages noted in the background.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a simplified diagrammatic view of an ear.

FIG. 2 illustrates a perspective view of one embodiment of an insertionsystem in an assembled configuration.

FIG. 3 illustrates a perspective view of the insertion systemillustrated in FIG. 2 in a disassembled configuration.

FIG. 4 illustrates a perspective view of another embodiment of aninsertion system in an assembled configuration.

FIG. 5 illustrates a perspective view of the insertion systemillustrated in FIG. 4 in a disassembled configuration.

FIGS. 6-7 illustrate related art ventilation tubes having specificfeatures that coordinate with an insertion system, such as the insertionsystems illustrated in FIGS. 2-5.

FIGS. 8-17 illustrate embodiments of ventilation tubes having specificfeatures that coordinate with an insertion system, such as the insertionsystems illustrated in FIGS. 2-5.

FIGS. 18-19 illustrate related art ventilation tubes having specificfeatures that coordinate with an insertion system, such as the insertionsystems illustrated in FIGS. 2-5.

FIGS. 20-36 illustrate further embodiments of ventilation tubes havingspecific features that coordinate with an insertion system, such as theinsertion systems illustrated in FIGS. 2-5.

FIG. 37 illustrates a related art ventilation tube having specificfeatures that coordinate with an insertion system, such as the insertionsystems illustrated in FIGS. 2 and 3.

FIGS. 38-43 illustrate still further embodiments of ventilation tubesthat coordinate with an insertion system, such as the insertion systemsillustrated in FIGS. 2-5.

FIGS. 44-47 illustrate embodiments of ventilation tubes comprisingmedial and lateral flanges with various wall thicknesses.

FIGS. 48-49 illustrate embodiments of ventilation tubes comprising mainbodies with varying wall thickness.

FIG. 50 illustrates an exploded view of the insertion end of theinsertion system illustrated in FIGS. 2 and 3.

FIGS. 51-52 illustrate various section views of various embodiments ofthe insertion end illustrated in FIG. 50.

FIG. 53 illustrates an exploded view of an alternative embodiment of aninsertion end.

FIG. 54 illustrates a section view of the insertion end illustrated inFIG. 53.

FIG. 55 illustrates a bottom view of the cutting sheath of the insertionsystem illustrated in FIGS. 2 and 3.

FIG. 56 illustrates a side view of the cutting sheath illustrated inFIG. 55.

FIG. 57 illustrates a bottom view of an alternative embodiment of acutting sheath.

FIG. 58 illustrates a bottom view of another alternative embodiment of acutting sheath.

FIGS. 59-64 illustrate different embodiments of a cutting sheath with avisual indicator or physical stop so as to provide the user with theability to determine depth of penetration.

FIG. 65 illustrates an enlarged view of another embodiment of aninsertion end a visual indicator or physical stop provided by a cuttingsheath or other element positioned outwardly from the cutting sheath.

FIG. 66 illustrates a side view of one embodiment of a cutting sheathwith a sensing element for detecting when the cutting sheath has madesufficient penetration.

FIG. 67 illustrates a bottom view of the cutting sheath illustrated inFIG. 66.

FIG. 68 illustrates another embodiment of an insertion end including apassive safety sheath located over a cutting sheath.

FIG. 69 illustrates a side view of the positioning rod illustrated inFIGS. 2 and 3.

FIGS. 70-73 illustrate enlarged views of various embodiments of a distalend of a positioning rod.

FIGS. 74-75 illustrate perspective views of various embodiments ofpositioning rods that include an interface for receiving an attachmentof or positioning of other devices along its side.

FIG. 76 is an end view of the insertion end of the insertion system ofFIGS. 2 and 3 illustrating the relationship between the cutting sheathand the positioning rod.

FIG. 77 is a side view of an alternative embodiment of the actuationmember of the insertion system illustrated in FIGS. 2 and 3.

FIG. 78 illustrates an enlarged exploded view of a nose of the noseassembly illustrated in FIGS. 2 and 3.

FIG. 79 illustrates enlarged assembled view of the nose of FIG. 78.

FIG. 80 illustrates an enlarged exploded view of a nose of the noseassembly illustrated in FIGS. 4 and 5.

FIG. 81 illustrates a partial perspective cut-away view of the handleassembly of the insertion system illustrated in FIGS. 2 and 3.

FIG. 82 illustrates a partial perspective enlarged view of the handleassembly of the insertion system illustrated in FIGS. 4 and 5.

FIG. 83 illustrates a section view of the handle assembly of theinsertion system illustrated in FIGS. 2 and 3.

FIG. 84 illustrates a section view of the handle assembly of theinsertion system illustrated in FIGS. 4 and 5.

FIG. 85 illustrates an enlarged perspective view of the assembled noseof the nose assembly and the rack of the handle assembly illustrated inFIGS. 2 and 3.

FIG. 86 illustrates a ventilation tube being radially loaded into thecutting sheath of the insertion system illustrated in FIGS. 2 and 3.

FIG. 87 illustrates a ventilation tube being axially loaded into thecutting sheath of the insertion system illustrated in FIGS. 2 and 3.

FIG. 88 illustrates an alternative embodiment for the loading tubeillustrated in FIG. 30.

FIG. 89 illustrates an alternative embodiment for a ventilation tube foraxially loading the tube into a cutting sheath.

FIG. 90 illustrates a flow chart describing a manual process forinserting a ventilation tube into a tympanic membrane of the body.

FIG. 91 illustrates a flow chart describing a semi-automatic process forinserting a ventilation tube into a tympanic membrane of the body.

FIG. 92 illustrates an embodiment of an insertion system includingelements which facilitate the semi-automated placement of ventilationtubes as illustrated in FIG. 91.

FIG. 93 illustrates yet another embodiment of an insertion systemincluding a removable element that can be slid onto the cutting sheathsuch that the cutting sheath is covered and protected.

FIG. 94 illustrates a section view and FIG. 95 illustrates an enlargedview of the insertion end of the insertion system of FIGS. 2 and 3interfacing with a speculum-like device.

FIGS. 96-98 illustrate an embodiment of a speculum-like device withunique features for interfacing with the insertion system illustrated inFIGS. 2 and 3.

DETAILED DESCRIPTION

Embodiments described herein are directed to various ventilation devicesor tubes, such as ear tubes, and insertion systems or devices forinserting ventilation devices or tubes into different membranes of abody. In one particular embodiment, a ventilation tube includes amaterial that allows the device to remain in a deformed state duringinsertion into a body. After insertion through a target membrane, it isallowed to re-form its flanges or members in-situ to anchor it in place.The deformed ear tube and the insertion device that places theventilation tube in the membrane allows for minimally invasiveventilation tube placement, which reduces the pain, cost and risksassociated with conventional procedures and devices.

FIG. 1 illustrates a system of organs in an ear 10 of a body thatenables a person to detect sound. Ear 10 is able to change soundpressure waves into a signal of nerve impulses to be processed by thebrain. Ear 10 includes an outer ear 12, a middle ear 14 and an inner ear16. Outer ear 12 collects sound and includes the pinna 18, the ear canal20 and an outer most layer of the ear drum or tympanic membrane (TM) 22.Pinna 18 helps direct sound through ear canal 20 to TM 22. Middle ear 14includes an air-filled cavity 24 having an opening for the Eustachiantube 26 that is located behind TM 22. Middle ear 14 also includesossicles bones 28. Inner ear 16 includes the fluid-filled cochlea 30 andthe semicircular canals 32. Cochlea 30 is the auditory portion of theinner ear, while semicircular canals 32 are attuned to both gravity andmotion. The ossicles bones 28 transmit sound from the air in cavity 24to cochlea 30. Fluid in cochlea 30 moves in response to the vibrationscoming from middle ear 14. The motion of the fluid is converted toelectrical impulses, which travel along the auditory nerve 34 tostructures in the brainstem for further processing. Eustachian tube 26couples cavity 24 of middle ear 14 to the nose and mouth of a human. Ina normal state, Eustachian tube 26 is collapsed. However, Eustachiantube 26 can open and close to equalize pressure in cavity 24.

An infection of the middle ear 14 can result in a buildup of fluid andincreased pressure in cavity 24 causing severe pain. Children are oftenprone to infections of middle ear 14 because of their underdevelopedEustachian tube 26. A myringotomy is a surgical procedure in which atiny incision is created in TM 22 to relieve pressure caused by theexcessive buildup of fluid due to an infection of the middle ear 14. Ifa patient requires a myringotomy, this generally suggests thatEustachian tube 26 is either partially or completely obstructed and isnot able to perform its proper functions

In some cases, besides making an incision in TM 22, a ventilation deviceor tube is inserted into the opening. Insertion of a ventilation orpressure equalizing (PE) device or tube can allow external ventilationof middle ear 14 for an extended period of time. However, in theconfined space of ear canal 20, especially an ear canal of a child,insertion of a ventilation device or tube can be difficult. In oneexample, the incision made in TM 22 is often made larger thancross-section area of the ventilation device or tube. In such anexample, the device will fall out much earlier than desired. In anotherexample, many surgical tools need to be used to insert the device, suchas a blade, a funnel (to visualize TM 22), forceps (to deliver thedevice), suction and a microscope. Therefore, much time is needed toprepare for the relatively simple surgery and additional time is neededduring the procedure to switch between uses of the differentinstruments. Although this relatively brief procedure can be performedon an outpatient basis, in general, children require a generalanesthetic such that they remain co-operative during the procedure.Administering anesthetic increases the time of the procedure as well ascost. A device that can alleviate these disadvantages can greatlyenhance patient comfort as well as reduce procedural time and undueinjury to TM 22, while simultaneously simplifying the procedure forphysicians.

As discussed above, embodiments described are directed towards devices,systems and procedures for delivering a ventilation structure or tube toa membrane of a body, such as tympanic membrane 22 for treatment of amiddle ear infection or otitis media. It should be realized, though,that embodiments described can be used to deliver and maintain anopening in any anatomical structure of the body whether the opening isnaturally occurring or surgically created. Examples include maintainingan opening created by a tracheostomy, a cricothyrotomy and the like. Inaddition, embodiments are not limited to just ear ventilation, but couldprovide communication between any two areas in a body separated by amembrane or barrier. In addition, embodiments described can be used todeliver materials intended to communicate between two areas in a body,such as a ‘wick’, positioned through the TM to transport antibioticsfrom the ear canal into the middle ear. Embodiments described are alsodirected to the ventilation structure or tube itself.

While embodiments of the ventilation device or tube are illustrated as ahollow body, the device can also be a plug with no internal passagewayfor closing or plugging an opening. A plug can be used to block openingsin a membrane, a vascular or vessel hole or create a mechanicalcommunication between two spaces separated by a membrane, such as amembrane of a sinus cavity. The device can also be used to createcommunication between two lumens such as formation of vascular shunts orapplied to the gastrointestinal tract and biliary system. The deployeddistal members of the device may also provide better positioning ofstents, in that, the larger ends can limit movement of the device/stent.For example, tracheal, bronchial, and esophageal stents are at high riskof movement from an originally deployed position. This is likely due tothe symmetrical cylinder shape of the stent/device. Also, the device canbe a minimally invasive way to deploy a trocar device/site.

FIG. 2 illustrates a perspective view of one embodiment of an insertionsystem 200 for inserting a ventilation device or tube into an anatomicalstructure or membrane of a body. In FIG. 2, insertion system 200 is inan assembled configuration. FIG. 3 also illustrates a perspective viewof insertion system 200, but in a disassembled configuration. FIG. 4illustrates a perspective view of another embodiment of an insertionsystem 200′ in an assembled configuration. FIG. 5 also illustrates aperspective view of insertion system 200′, but in a disassembledconfiguration. Insertion system 200 or 200′ includes two primaryassemblies: a nose assembly 203 or 203′ and a handle assembly 205 or205′. As illustrated in FIG. 3, nose assembly 203 or 203′ can becompletely detached from handle assembly 205 or 205′.

Nose assembly 203 or 203′ includes a hollow cutting sheath 206 or 206′,a hollow positioning rod 204 or 204′, a nose 213 or 213′ and anactuation member 214 (illustrated in FIGS. 50, 51 and 52) that extendsfrom nose 213 or 213′ through the inside of positioning rod 204 or 204′to attach to cutting sheath 206 or 206′. An insertion end or distal end202 or 202′ of insertion system 200 or 200′ defines the distal end ofnose assembly 203 or 203′ and is the end to which positioning rod 204 or204′, cutting sheath 206 or 206′ and actuation member 214 interact todeploy a ventilation tube to a tissue or membrane of a body. Inparticular, cutting sheath 206 or 206′ surrounds a distal portion ofpositioning rod 204 or 204′ at insertion end 202 or 202′. Handleassembly 205 or 205′ defines an actuation end or proximal end 208 or208′ of insertion system 200 or 200′. Handle assembly 208 or 208′includes a handle 212 or 212′, an actuation mechanism (of which only arotatable actuating element or scroll wheel 210 or 210′ is illustratedin FIGS. 2, 3, 4 and 5) and a nose interface 217 or 217′ for interfacingwith nose assembly 203 or 203′. As illustrated in FIGS. 4 and 5, in oneembodiment, a plurality of mechanical bumps 299′ are located on anexterior surface of handle 212′ to provide a better grip to a user orclinician during use, especially a user clinician who is wearing gloves.Mechanical bumps 299′ can be raised portions of the material handle212′, made of an overmold material with high frictional properties,include stickers or labels and the like.

In order for insertion system 200 or 200′ to function, at least aportion of a ventilation tube is deformed from its default or a reststate into a smaller constrained state. Cutting sheath 206 or 206′ isthe component that holds the portion of the ventilation tube in thedeformed state. After cutting sheath 206 or 206′ is advanced through theTM such that the ventilation tube is positioned correctly across the TM,cutting sheath 206 or 206′ is retracted while the ventilation tube isheld in place by positioning rod 204 or 204′.

During cutting sheath 206 or 206′ retraction, the initial staticfriction between the ventilation tube and cutting sheath 206 or 206′needs to be overcome to allow the ventilation tube to start to slide outof the sheath. The sliding friction needs to be continuously overcome toallow cutting sheath 206 or 206′ to be successfully retracted, leavingthe ventilation tube in position across the TM. More specifically, Thefrictional force between the ventilation tube and cutting sheath 206 or206′ needs to be sufficient enough such that the ventilation tube isretained in cutting sheath 206 or 206′ before cutting sheath 206 or 206′is retracted, but small enough that cutting sheath 206 or 206′ can beretracted and be left in the TM.

Before discussing insertion system 200 and 200′ in detail, the followingis a detailed discussion of ventilation tubes in general and variousembodiments of ventilation tubes that can be used with insertion system200 or 200′ for inserting into a tissue or membrane of the body. One wayto control the frictional force is to control the surface area betweenthe ventilation tube and cutting sheath 206 or 206′. As will beexemplified below, to keep frictional forces low, a majority of thelength of a ventilation tube may be not in direct contact with cuttingsheath 206 or 206′ by slightly undersizing the axial body of the tubecompared to an inner lumen diameter of cutting sheath 206 or 206′.Therefore, the only portions of the ventilation tube that are in adeformed state are the flange or flanges. It is also possible to controlthe surface area between the ventilation tube and cutting sheath 206 or206′ based on the geometry of the flange or flanges of the tube. Thediameter of the flange or flanges can be made larger or smaller toincrease or decrease contact area and therefore increase or decreasefriction. Portions of the flange or flanges can be removed or added orother features that do not function as flanges can be added or removedto increase or decrease contact area.

Another way to control the frictional force is to control the normalforce between the ventilation tube and cutting sheath 206 and 206′. Aswill be exemplified below, a thickness of the flange or flanges can becontrolled. For example, a thicker, more structural flange exerts alarger outward force and increased friction. The choice of material forthe ventilation tube also can impact friction forces. Tubes that resistdeformation generate greater normal forces. For example, a tube materialwith a durometer appropriate for maintaining axial rigidity duringdeployment without generating excessive radial normal forces result canbe chosen. The tube needs to be stiff enough that it can be pushed outof cutting sheath 206 or 206′ without collapsing axially, but softenough that the flange or flanges can be compressed without generatingtoo high of a friction force.

A third way to control the frictional force is to control thecoefficient of friction between the ventilation tube and cutting sheath206 and 206′ by altering the surface of one or both of the ventilationtube and cutting sheath 206 or 206′, by selecting specific materials ofone or both of the ventilation tube and cutting sheath 206 or 206′ orintroducing a surface modifying agent to one or both of the ventilationtube and cutting sheath 206 and 206′. For example, providing a finetexture to the inside of cutting sheath 206 or 206′ can reduce frictionbetween the ventilation tube and cutting sheath 206 or 206′ by reducingthe contact surface area on a microscopic level. Likewise, texturing oneor more surfaces on the ventilation tube can have a similar effect. Inanother example, surface coatings or treatments can be applied to theventilation tube or cutting sheath 206 or 206′ to modify theirfrictional properties. For example, the tube could b molded from amaterial is naturally lubricious or has an inherent lubricant, such asself-lubricating silicone rubber (i.e., Nusil MED1-4955). Cutting sheath206 or 206′ could be coated with parylene to alter frictional propertieswithout negatively impacting its cutting capabilities. In addition,tubes could be made from one or more materials with different propertiesto optimize for strength and surface properties where needed. Forexample the axial body could be made of a stiffer material, while theflange or flanges or other features that are to be compressed ordeformed could be made of a softer material and/or of a material with alower coefficient of friction. Further, lubricant, such as a siliconegrease or oil, sterile saline or other suitable liquid can be placed onor between the tube and cutting sheath 206 or 206′. Still further, thetube can be given a partial “set” in the deformed position in cuttingsheath 206 or 206′. This can be done over time or accelerated with heat.For example, a tube loaded into a sheath exhibits a certain normal forceand resulting frictional resistance to deployment that can change overtime as the material in the tube “relaxes” in the deformed state. Thisrelaxation can be accelerated, for example, by exposing the tube toelevated temperatures.

Still further, axial compression of a ventilation tube, or otherdelivered object, may be desirable in certain applications. The frictionbetween the ventilation tube and the cutting sheath can be used toaxially compress the body of a tube, shortening the space between twopoints along it's body. For example, the distance between a medialflange and a visualization tab on a tube may be longer in its natural,relaxed state than when it is compressed inside a cutting sheath. Inthis embodiment, the tube would be loaded into the cutting sheath, andthe cutting sheath may be retracted along the positioning rod such thatthe tube is compressed axially inside the cutting sheath, decreasing thedistance between the medial flange and visualization tab. Additionalretraction would result in no or minimal additional axial compressionbefore restraining frictional forces would be overcome and the tubewould be deployed.

FIGS. 6-49 illustrate ventilation or tympanostomy tubes with specificfeatures that improve their ability to function in conjunction withinsertion system 200 illustrated in FIGS. 2 and 3 and with insertionsystem 200′ illustrated in FIGS. 4 and 5. In particular, FIGS.-6-17describe grommet-type ventilation tubes. FIGS. 18-36 describe avariation of grommet-type ventilation tubes and FIGS. 37-43 describeT-tube type ventilation devices.

FIGS. 6 and 7 illustrate exemplary grommet-type tubes that exist in theprior art, while FIGS. 8-17 illustrate grommet-type tubes according tovarious embodiments of the disclosure. FIG. 6 illustrates exemplaryprior art grommet-type ventilation tube 315 a. Grommet tube 315 aincludes a hollow main body 382 a having parallel flanges. Inparticular, grommet-type tube 315 a includes a medial flange 384 a thatis to be located internal to the TM of a patient and a lateral flange386 a to be located external to the TM of a patient. As illustrated,medial flange 384 a includes an outer diameter that is greater than anouter diameter of lateral flange 386 a. In this way, grommet-type tube315 a is less likely to fall out of the TM too early.

FIG. 7 illustrates an exemplary prior art grommet-type ventilation tube315 b known as a Paparella grommet tube. Grommet tube 315 b iscommercially available through many ventilation tube manufacturersincluding, but not limited to, Summit Medical, Inc. of St. Paul, Minn.Like tube 315 a, tube 315 b includes a hollow main body 382 b having amedial flange 384 b and a lateral flange 386 b. Unlike tube 315 a,grommet tube 315 b also includes a tab 388 b located on lateral flange386 b and a notch 390 b located on medial flange 384 b. In conventionalapplications, tab 388 b is grasped with an instrument, such as aforceps, and notch 390 b is provided to help insert medial flange 384 bthrough the tissue. For use with insertion system 200, tab 388 b is bentsubstantially perpendicularly from the outer diameter of lateral flange386 b when loaded into cutting sheath 206 such that tab 388 b is allowedto protrude through a slot in cutting sheath 206 for purposes ofvisualization, while medial flange 384 b and lateral flange 386 b arecompressed in the cutting sheath for later deployment.

In the alternative, FIGS. 8, 9 and 10 illustrate a perspective view, aside view and a section view of a ventilation tube 315 c according toone embodiment Like tubes 315 a and 315 b, tube 315 c includes a hollowmain body 382 c having a medial flange 384 c, a lateral flange 386 c, anotch 390 c and visualization tab 388 c. Rather than having a tab thatextends in a lateral direction 383 c along the outer diameter of thelateral flange and must be bent substantially perpendicular from thelateral direction in its loaded configuration as is the case with tube315 b, visualization tab 388 c is formed to extend from the outerdiameter of the lateral flange 386 c, but in a direction substantiallyperpendicular to the lateral direction 383 c. In this way, visualizationtab 388 c need not be manipulated during loading to cause the tab toextend through the slot in the cutting sheath 206 because it is premadeto do so. Visualization tab 388 c includes a wider distal end than aproximal end that is coupled formed with lateral flange 386 c. In oneembodiment, the width at the proximal end approximately corresponds withthe width of the slot in the cutting sheath through which visualizationtab 388 c protrudes through, while the width of the distal end isgreater than the width of the slot in the cutting sheath.

Compared to FIGS. 8-10, tube 315 d and 315 e of FIGS. 11 and 12illustrate that some or all of lateral flange 386 c could be removedwhen the tube is formed according to alternative embodiments. Comparedto FIGS. 8-10, FIG. 13 illustrates a tube 315 f with an additional notch391 f on medial flange 384 c, which in FIG. 13 is located opposite notch390 c according to another alternative embodiment. Removing a portion orportions of the medial or proximal flanges 384 c or 386 c can reduce theamount of flange material that must be compressed inside the sheathcomponent, making it easier to load and/or deploy the ventilation tube.In addition, the location of a notch can provide a preferential locationfor the flange to fold during loading into a cutting sheath. Predictablefolding into a cutting sheath allows for a more repeatable process forloading and for deploying, and allows for a planned ‘compressed’ statethat the ventilation tube flanges will occupy while constrained withinthe sheath.

Compared to FIGS. 8-10, FIG. 14 illustrates a tube 315 g with a medialflange 384 g that is thinner than a standard ventilation tube, and alateral flange 386 g of varying thickness according to yet anotheralternative embodiment. It should be understood that one, both or noneof the medial or lateral flanges could be thinner, or could be ofvarying thickness. Providing a thinner flange reduces the amount ofmaterial in the flange, allowing it to be constrained inside of acutting sheath with a smaller inside diameter. Medial and lateralflanges of varying thickness combine the benefit of a thinner flange inreducing overall mass, while retaining strength and physical propertieswhere needed. For example, the thicker part of the flange in FIG. 14 islocated proximal to tab 388 c that interfaces with the slot in thecutting sheath 206. To ensure that tab 388 v remains positionedcorrectly, a slightly thicker flange support may be desirable.

Compared to FIG. 14, FIG. 15 illustrates a tube 315 h with a slotinterface element 393 h located along the length of hollow main body 382c according to yet another alternative embodiment. Slot interfaceelement 393 h may provide additional interface area between the tube 315h and a cutting sheath to maintain registration during loading ordeployment. It may also provide additional strength along the length ofthe hollow main body 382 c of the tube to prevent the tube fromcollapsing longitudinally during deployment from the cutting sheath.

Compared to FIG. 14, FIG. 16 illustrates a ventilation tube with a notch394 i on lateral flange 386 g. A notch or plurality of notches onlateral flange could provide a material reduction to allow the notch tofold along predictable bends during insertion into the sheath component.In addition, the location of notches, or gaps in the lateral flangecould allow for loading tools or accessories to pass along and throughthe flange at those points. A notch or notches could also allowventilation tube 315 i to be registered to a loading tool or accessoryto aid in subsequent registration and loading into a sheath component.

In yet another alternative embodiment and compared to FIGS. 7-10, FIG.17 illustrates a ventilation tube 315 j with a tab 388 j that isdifferent than tab 388 b or visualization tab 388 c of tubes 315 b or315 c. Rather than having a tab that extends in a lateral direction 383c along the outer diameter of the lateral flange and must be bentsubstantially perpendicular from the lateral direction in its loadedconfiguration as is the case with tube 315 b or a visualization tab 388c that extends from the outer diameter of the lateral flange 386 c in adirection substantially perpendicular to the lateral direction 383 c,visualization tab 388 j has a thickness that corresponds with thethickness of the lateral flange 386 c and extends outward at a tangentfrom the outer diameter of lateral flange 386 c.

FIGS. 18 and 19 illustrate exemplary grommet-type tubes that exist inthe prior art, while FIGS.-20-33 illustrate grommet-type tubes accordingto various embodiments of the disclosure. FIG. 18 illustrates exemplaryprior art grommet-type ventilation tube 415 a known as an Armstronggrommet tube that does not have parallel flanges. Grommet tube 415 a iscommercially available through many ventilation tube manufacturersincluding, but not limited to Summit Medical, Inc. of St. Paul, Minn.Grommet tube 415 a includes a hollow main body 482 a having a medialflange 484 a that is to be located internal to the TM of a patient and alateral flange 486 a to be located external to the TM of a patient. Asillustrated, medial flange 484 a includes a bevel that corresponds to anangle that makes it easier to insert tube 415 a into a TM of a patient.While presenting a beveled medial end to a TM during insertion to makeit easier to insert, the lateral end of the tube should be “squared” forpresenting to the positioning rod of the insertion system. Of course, itis possible that the lateral end could be “non-square” as long as thefrictional force resisting deployment is low enough.

FIG. 19 illustrates another exemplary prior art grommet-type ventilationtube 415 b, which is the Armstrong grommet tube with a tab 488 b.Grommet tube 415 b is also commercially available through manyventilation tube manufacturers including, but not limited to SummitMedical, Inc. of St. Paul, Minn. Like tube 415 a, tube 415 b includes ahollow main body 482 b having a beveled medial flange 484 b and alateral flange 486 b. Unlike tube 415 a, grommet tube 415 b alsoincludes a tab 488 b located on lateral flange 486 b. In conventionalapplications, tab 488 b is grasped with an instrument, such as aforceps. For use with insertion system 200, tab 488 b is bentsubstantially perpendicularly from the outer diameter of lateral flange486 b when loaded into cutting sheath 206, such that tab 488 b isallowed to protrude through a slot in cutting sheath 206 for purposes ofvisualization, while medial flange 484 b and lateral flange 486 b arecompressed in the cutting sheath for later deployment.

Similar modifications to those illustrated in FIGS.-6-16 can be appliedto tubes 415 a and 415 b. For example, FIG. 20 illustrates a ventilationtube 415 c according to one embodiment. Like tubes 415 a and 415 b, tube415 c includes a hollow main body 482 c having a medial flange 484 c, alateral flange 486 c and visualization tab 488 c. Rather than having atab that extends in a lateral direction 483 c along the outer diameterof the lateral flange and must be bent substantially perpendicular fromthe lateral direction in its loaded configuration as is the case withtube 415 b, visualization tab 488 c is formed to extend from the outerdiameter of the lateral flange 486 c, but in a direction substantiallyperpendicular to the lateral direction 483 c. In this way, visualizationtab 488 c need not be manipulated during loading to cause tab 488 c toextend through the slot in the cutting sheath 206 because it is premadeto do so. Visualization tab 488 c includes a wider distal end than aproximal end that is formed with lateral flange 486 c. In oneembodiment, the width at the proximal end approximately corresponds withthe width of the slot in the cutting sheath through which visualizationtab 488 c protrudes through, while the width of the distal end isgreater than the width of the slot in the cutting sheath.

Compared to FIG. 20, tube 415 d and 415 e of FIGS. 21 and 22 illustratethat some or all of lateral flange 486 c could be removed when the tubeis formed according to alternative embodiments. Compared to FIG. 20,FIG. 23 illustrates a tube 415 f with a notch 490 f in medial flange 484c and FIG. 24 illustrates a tube 415 g with a second notch 491 g inmedial flange 484 c, which in FIG. 24 is located opposite notch 390 caccording to another alternative embodiment.

Compared to FIG. 24, FIG. 25 illustrates a tube 415 h with a lateralflange 486 h of varying thickness according to yet another alternativeembodiment. Compared to FIG. 24, FIG. 26 illustrates a tube 415 i with aslot interface element 493 i located along the length of hollow mainbody 482 c according to yet another alternative embodiment. Slotinterface element 493 i may provide additional interface area betweenthe tube 415 i and a cutting sheath to maintain registration duringloading or deployment. Compared to FIG. 26, FIG. 27 illustrates aventilation tube 415 j with a notch 494 j in lateral flange 486 c. Anotch or plurality of notches on lateral flange could provide a materialreduction to allow the notch to fold along predictable bends whenlocated into the cutting sheath. In addition, the location of notches,or gaps in the lateral flange could allow for loading tools oraccessories to pass along and through the flange at those points. Anotch or notches could also allow ventilation tube 415 i to beregistered to a loading tool or accessory to aid in subsequentregistration and loading into a sheath component.

FIG. 28 illustrates a perspective view of yet another alternativeembodiment of a ventilation tube 415 k. In this embodiment, the hollowmain body or lumen 482 k of ventilation tube 415 k extends from medialflange 484 a and beyond visualization tab 488 c. In cases where a longhollow main body is desired, as is shown in FIG. 28, the lateral flangeor the visual indicator 488 c may not be located at the far lateral endof the tube so that the visual indicator can be used to determinecorrect placement without excessive penetration behind the TM whichcould damage the back wall of the inner ear. As shown, hollow main body482 k extends past visualization tab 488 c to ensure that the tube doesnot fall inside the TM, even if the device is slightly over-insertedthrough the TM. FIG. 29 illustrates a perspective view of yet anotheralternative embodiment of a ventilation tube 415L. Like FIG. 19, tab4881 extends in a lateral direction from the outer diameter of thelateral flange 486 c, but includes a tab having a wider distal end thana proximal end.

FIG. 30 illustrates a perspective view of yet another alternativeembodiment of a ventilation tube 415 m. In this embodiment, like tube415 k, the tube 415 m includes hollow main body or lumen 482 k thatextends from medial flange 484 m and beyond visualization tab 488 m. Asshown, hollow main body 482 k extends past the lateral flange orvisualization tab 488 m to ensure that the tube does not fall inside theTM, even if the device is inserted too far through the TM. FIG. 31illustrates a perspective view of yet another alternative embodiment ofventilation tube 415 n. Ventilation tube 415 n is like ventilation tube415 m, except, medial flange 484 n is trimmed along edge 490 n. Trimmededge 490 n increases the clearance between medial flange 484 n andvisualization tab 488 m, providing more leeway on placement across theTM. FIG. 32 illustrates a perspective view of yet another alternativeembodiment of a ventilation tube 415 o. Like tube 415 n, tube 415 oincludes a trimmed medial flange 484 n and visualization tab 488 m.However, hollow main body or lumen 482 o extends beyond visualizationtab 488 m a shorter axial length. To compensate for the shorter axiallength, an extra lateral tab 486 o, besides the use of visualization tab488 m as a lateral flange, substantially opposes visualization tab 488 mto keep the tube from falling inside or behind the TM. In addition,lateral tab 486 o can be folded back while it is loaded in the cuttingsheath so that it is positioned as far away from the cutting edge of thecutting sheath as possible to ensure that it is deployed last, or as farlateral as possible, minimizing the chance of over-insertion duringdeployment.

FIG. 33 illustrates a perspective view of yet another alternativeembodiment of a ventilation tube 415 p. In this embodiment, like tube415 n, tub 415 p includes a trimmed medial flange 484 n and a lateralflange or visualization tab 488 m. However, the portion of hollow mainbody or lumen 482 p that extends past visualization tab 488 m is splitalong its axial length from visualization tab 488 m to lateral end 487 pfor preventing the inner lumen from plugging with effusion. The splitprovides many advantages. For example, the split minimizes the axiallength of the inner lumen of tube 415 p, the split provides a shortersection of small diameter inner lumen, the split helps to hold the tubefrom falling into the middle ear post deployment by acting as a lateralflange and the split makes it easier to unplug a tube that has becomeplugged.

In addition, while the minimum distance between the medial and lateralflanges for the tubes shown in FIGS. 6-17 can only be increased ordecreased by changing the length of the hollow main body, as illustratedin FIGS. 34, 35 and 36, this distance 496 q-1, 496 q-2 and 496 q-3 canbe modified for the tubes shown in FIGS.-18-27 by changing the placementof either medial flange 484 q-1, 484 q-2 and 484 q-3 or lateral flange486 q-1, 486 q-2, and 484 q-3 or by removing or trimming the medialflange 484 q-2 as illustrated in FIG. 35 (i.e., any flange that is notpositioned at a right angle to the axis of the hollow main body of agrommet-type ventilation tube). Placement of the medial flange changesthe distance between the lateral and medial flanges (whether smaller orlarger) to make insertion of the ventilation tube easier. Because theuser must position the device across the TM using visual indicators ofdepth, a longer hollow main body would allow for a larger range ofacceptable positioning of the tube which results in successfuldeployment across the TM.

FIG. 37 illustrates another exemplary tube style commonly referred to asa T-tube, while FIGS.-38-41 illustrate T-tubes type tubes according tovarious embodiments of the disclosure. FIG. 37 illustrates exemplaryprior art T-tube type ventilation tube 515 a, which is commerciallyavailable through many ventilation tube manufacturers including, but notlimited to Summit Medical, Inc. of St. Paul, Minn. T-tube 515 a includesa hollow main body 582 a having a pair of medial flanges 584 a and 585 athat are to be located internal to the TM (TM) of a patient.

FIGS.-38-41 illustrate modifications similar in intended function asthose shown for grommet style tubes. FIG. 38 shows a T-tube styleventilation tube 515 b with a visualization tab 588 b located at andextending from lateral end 587 b according to one embodiment.Visualization tab 588 b is intended to interface with a slot in thecutting sheath component of insertion system 200. In this embodiment,the visualization tab 588 b protrudes radially from the hollow main body582 a of ventilation tube 515 b (i.e., substantially perpendicular to anaxial direction of the tube), but it should be understood thatvisualization tab 588 b could be oriented at any angle to the axis ofthe hollow main body of the tube. In addition, visualization tab 588 bmay be located at the lateral end or anywhere along the length of thehollow main body of the tube.

FIG. 39 illustrates another embodiment where the tab intended tointerface with a sheath in a sheath element of an insertion device isoriented along or parallel to the main axis of the main body of theventilation tube. In this embodiment, visualization tab 588 c would needto be deformed outward during or after insertion into the sheath so thatit would extend radially outward to provide a visual indicator of depthor a physical stop. FIG. 5D illustrates another embodiment with anaxially aligned visualization tab 588 c and a radially locatedvisualization tab 589 d. In this embodiment, the axially alignedvisualization tab 588 c could be bent or positioned through a slot inthe cutting sheath to provide a physical or visual stop. The radiallylocated visualization tab 589 d located along hollow main body 582 acould additionally register the tube with the slot in the cuttingsheath. Furthermore, tab 589 d could provide longitudinal strength tohollow main body 582 a to prevent the tube from collapsing along itslongitudinal axis when the cutting sheath is retracted. In FIG. 5D, theradial tab is located along a portion of the hollow main body of theventilation tube that would normally be located lateral to the TM, butthe visualization tab 589 d could extend along the full length of thehollow main body 582 a, along the portion normally located behind theTM, or along any other portion thereof.

FIG. 41 illustrates a tube 515 e with two visualization tabs 588 c and588 d shaped to interface with a slot on a cutting sheath of insertionsystem 200. In instances where the pair of medial flanges are longercompared to the hollow main body of the tube, or in cases where thehollow main body of the tube itself is elongated, having twovisualization tabs that extend through a slot on a cutting sheath may bedesirable. For example, tube 515 e could be inserted so that the medialvisualization tab 588 d is located just outside the TM, which wouldensure that the pair of medial flanges would be located past the TM forcorrect deployment. The lateral visualization tab 588 b could then beused to verify that the tube was fully deployed from the cutting sheathof insertion system 200. In addition, a single tab or registrationfeature extending along the outside of a ventilation tube and intendedto interface with a cutting sheath of an insertion system could belocated to provide the same functionality as a number of tabs inindicating correct device positioning with the TM during insertion.

FIG. 42 illustrates a tube 515 f having a lateral flange orvisualization tab 588 f. Tube 515 f is similar to tube 515 b, however,visualization tab 588 f is not located at a lateral end 587 f of hollowmain body 582 a, but along the length of hollow main body 582 a. Asshown, hollow main body 582 a extends past visualization tab 588 f. Inone embodiment, the extended length ensures that the tube does not fallinside the TM, even if the device is inserted too far through the TM.FIG. 43 illustrates a tube 515 g. Tube 515 g is similar to tube 515 f,however, rather than tube 515 g having a pair of medial flanges that arecurved as is shown in FIGS. 37-42, tube 515 g has a pair of medialflanges 584 f and 585 f that are flat. Flat medial flanges 584 f and 585f are one example of a geometry that provides less frictional forcesinside a cutting sheath and make deployment easier.

FIGS. 44-47 illustrate ventilation tubes and corresponding crosssections exhibiting variations in flange thickness and hollow main bodythickness. FIG. 44 illustrates a side view of a ventilation tube 615 aand FIG. 45 illustrates a section view of ventilation tube 615 a. Tube615 a includes a hollow main body and parallel flanges that are of thesame outer diameter, but one flange is thinner where it joins the mainbody than the other. Such a construction could allow for easierdeformation and improved folding of the thinner flange during loadingand retention in a cutting sheath of an insertion system. In addition,FIGS. 44 and 45 also show a flange that has variable radial thickness(i.e., a flange that is thinner near the hollow main body of the tubeand thicker near the outer radius of the flange). The thinner flangesection near the hollow main body improves bending or deforming of thetube for loading into a cutting sheath, while the thicker outer edgeretains sufficient physical properties to allow the flange to return toits pre-deformed shape upon deployment from the sheath.

FIG. 46 illustrates a side view of a ventilation tube 615 b and FIG. 47illustrates a section view of ventilation tube 615 b. Tube 615 bincludes parallel flanges that are of the same outer diameter and ahollow main body there between. In FIGS. 46 and 47, the thickness of thehollow main body varies along the tube's axial length. Shown is a thinsection of the body located near both the lateral and medial flangeswhich would improve the bending and deformation of the tube at thosepoints for insertion into a sheath element. It should be noted that thethin section could be at just one end or the other, or if a flange wasnot fully circumferential, the thin section of the body could be limitedto a portion of the circumference of the body. The ability to maintainthicker body sections while providing thinner sections allows the tubeto be easily deformed for insertion into a sheath, but still include thenecessary axial stiffness to maintain axial length during deployment(i.e. not compressed longitudinally when deployed from a cuttingsheath).

FIG. 48 illustrates an end view of a ventilation tube 715 and FIG. 49illustrates a section view of ventilation tube 715. Tube 715 includes athicker portion of the hollow main body running the entire axial lengthof the tube. This construction allows for a tube that has structuralstiffness in an axial direction while providing greater flexibility forcompression and folding of the flanges for insertion into a sheathelement.

With reference back to insertion systems 200 and 200′, FIG. 50 is apartial exploded view of insertion end 202 of insertion system 200 andFIG. 51 is an enlarged sectional view of insertion end 202 of insertionsystem 200. Although FIGS. 50 and 51 refer back to insertion system 200,it should be understood that FIGS. 50 and 51 also represent the samecomponents in insertion system 200′. Cutting sheath 206 surrounds adistal portion of positioning rod 204 including a distal end 207 and isconfigured to receive a ventilation tube 215 constrained within theboundaries of cutting sheath 206. Positioning rod 204 is a hollow bodythat attaches to handle 212 through nose 213, bends along an angle 216and, in one embodiment, includes a slot or channel 222 in the distalportion. Actuation member 214 can be made of a flexible material, suchas but not limited to plastic or thin metal wire, and runs from aportion of an actuation mechanism including rotatable actuating element210 housed within handle 212, extends through and/or down the inside ofpositioning rod 204 and cutting sheath 206 and is fixedly attached tocutting sheath 206 at an attachment area 218. In alternativeembodiments, the connection between actuation member 214 and cuttingsheath 206 can be a removable connection.

Cutting sheath 206 includes an aperture 220 that extends entirelythrough a thickness 235 of a wall of cutting sheath 206. Aperture 220allows actuation member 214 to transition from an area internal tocutting sheath 206 to an area external to cutting sheath 206. Aperture220 also defines attachment area 218 by providing access to form a jointbetween actuation member 214 and cutting sheath 206, making it possibleto weld or otherwise bond actuation member 214 to cutting sheath 206. Inone embodiment, a distal end 221 of actuation member 214 is welded toaperture 220 to fixedly attach it to cutting sheath 206. For example,distal end 221 of actuation member 214 can be plug welded to aperture220. In this embodiment, slot 224, which allows for the protrusion of atab or visualization tab (such as those visualization tabs discussed inFIGS. 3-7), can also be used to allow access to the plug weld thatattaches actuation member 214 to aperture 220 in cutting sheath 206.

FIG. 52 is similar to FIG. 51, however, rather than ventilation tube 215being loaded into cutting sheath 206, in FIG. 52, ventilation tube 415 ois loaded into cutting sheath 206. In FIG. 52, lateral tab 486 o isfolded back and visualization tab 488 m protrudes through slot 488 m.Since tube 415 o includes a medial flange 484 m that is tapered like thebeveled distal edge 209 of cutting sheath 206, tube 415 o can be placedcloser to distal edge 209 than tube 215, which minimizes the insertiondepth required to deploy behind the TM. Minimizing insertion depth isbetter in situations where the TM is retracted.

In another embodiment and as illustrated in FIG. 53, which is a partialexploded view of an alternative insertion end 302 of insertion system200, and in FIG. 54, which is an enlarged sectional view of insertionend 302, it is possible to attach an actuation member 314 to a cuttingsheath 306 at an attachment area 318 by allowing access to theattachment area utilizing a slot 324 that extends entirely through thethickness 235 of a wall of cutting sheath 306 that is located oppositeof where aperture 220 in cutting sheath 206 is located. Slot 324 spans alength from a distal end or cutting edge 309 of cutting sheath 306 to atermination area and can be used to pass appropriate instruments throughthe wall of cutting sheath 306 for joining actuation member 314 to aninternal wall of cutting sheath 306. For example, actuation member 314can be joined to cutting sheath 306 by welding or otherwise bonding. Inthis embodiment, an aperture, such as aperture 220 of insertion end 202,is not needed. Both insertion end 202 and 302 already include slot 224or 324 to allow for the protrusion of a tab or visualization tab (suchas those visualization tabs discussed in FIGS. 6-49) of ventilation tube215 or 315. In still another embodiment, a different slot could extendentirely through the thickness of a wall of cutting sheath 306, butspans a length from a proximal end 311 to a terminating area of cuttingsheath 306 for this same purpose.

With reference back to FIGS. 50-52, in addition, actuation member 214can travel in slot or channel 222 of positioning rod 204. In oneembodiment, slot or channel 222 intersects with distal end 207, extendsentirely through a thickness 237 of a wall of positioning rod 204 andincludes a length 223 that spans from distal end 207 of positioning rod204 to a terminating area that is surrounded or covered by cuttingsheath 206. Ensuring slot 222 is covered by cutting sheath 206 isimportant in preventing loss of suction when insertion system undergoesa suction functionality. Slot or channel 222 registers cutting sheath206 to positioning rod 204. In an alternative embodiment, cutting sheath206 could extend a larger distance from distal end 207 of positioningrod 204 than that which is illustrated in FIG. 9 such that the entirerange of motion of actuation member 214 occurs at a point beyond distalend 207 of positioning rod, such that slot or channel 222 is notrequired.

In still another embodiment and in instances where actuation member 214does not interface with a slot or channel 222 in positioning rod 204 toprovide a means of registration for cutting sheath 206, the geometry ofactuation member 214 could provide a means of registration. For example,a round steel wire would limit the degree of rotation that cuttingsheath 206 can achieve. In another example, a flat wire or the use oftwo or more actuation members attached at different locations on cuttingsheath 206 could also be employed to reduce the achievable angle ofrotation between cutting sheath 206 and positioning rod 204. Because ofthe bend that actuation member 214 takes as it travels inside the bendarea of positioning rod 204, the torsional rigidity of a flat actuationmember 214 could be enhanced further to minimize angular displacement ofcutting sheath 206 in relation to positioning rod 204. The geometry ofactuation member 214 will be further discussed below.

As illustrated in FIGS. 51 and 52, actuation member 214 is attached toaperture 220 of cutting sheath 206 a sufficient distance from a distalend 209 of cutting sheath 206 so as not to interfere with the placementof tube 215 distal to joint 218. In particular, FIGS. 50-52 showactuation member 214 attached closer to distal end or cutting edge 209of cutting sheath 206 than to proximal end 211 of cutting sheath 206. Inembodiments where actuation member 214 travels in slot or channel 222 inpositioning rod 204, the location where actuation member 214 is attachedto aperture 220 minimizes the length required of channel 222 inpositioning rod 204 and improves manufacturability. It should berealized, however, the attachment between the actuation member 214 andcutting sheath 206 can be located anywhere along the internal lumen orwall of cutting sheath 206.

FIG. 55 illustrates a bottom view of cutting sheath 206 and FIG. 56illustrates a side view of cutting sheath 206 according to oneembodiment. FIGS. 55 and 56 illustrate cutting sheath 206 with asharpened, beveled distal end or cutting edge 209 and a slot 224extending from the sharpened, beveled distal end or cutting edge 209 toa terminating end 225. In one embodiment, the overall length 226 ofbeveled end 209 is minimized, as this portion must extend past thetympanic membrane into the constrained space of the middle ear duringventilation tube placement and not interfere with the highly sensitivebones and organs in the middle ear. To minimize length 226, beveled end209 includes a primary bevel angle 228 that is relative to a wall 230 ofcutting sheath 206. For example, primary bevel angle 228 can rangebetween approximately 30 degrees and 40 degrees.

Additional grinding steps can be taken to enhance the cutting ability,or sharpness, of beveled distal end or cutting edge 209. As illustratedin FIGS. 55 and 56, at least one set of lancet grinds are used toproduce lancet edges 232 and 233. The lancet grinding step is capable ofremoving additional overall length from the beveled area, which furthershortens the portion of the cutting sheath that must extend into themiddle ear during ventilation tube placement. In one exemplaryembodiment, beveled length 226 of a 15 gauge cutting sheath (outerdiameter of 0.072 in. or 1.829 mm) with a 30 degree primary bevel incombination with secondary lancet grinds can be less than 0.10 in. or2.54 mm. In another exemplary embodiment, beveled length 226 of a 15gauge cutting sheath (outer diameter of 0.072 in. or 1.83 mm) with a 40degree primary bevel in combination with secondary lancet grinds can beless than 0.075 in. or 1.905 mm.

In cases where the TM is already perforated or an incision is made withanother instrument or when there is insufficient room behind the TM(i.e., severe TM retraction), cutting sheath 206 can include a minimalbevel or no bevel. For example, cutting sheath 206 could be made with anapproximate 70 degree bevel and can be combined with a tube havinglittle or no bevel on the medial flange.

A lancet grind, or comparable sharpening procedure which producescutting edges located along the outer diameter of the cutting sheath arepreferred when a ventilation tube is loaded into the cutting sheath 206by inserting it axially from the distal end or cutting edge 209 of thecutting sheath 206. Sharp edges on the inner diameter of the cuttingsheath 206, such as those achieved with a back-grind style ofsharpening, tend to catch or cut the tube during such a loading process.Methods of loading a ventilation tube into cutting sheath 206 will bediscussed in detail below.

Cutting sheath 206 can be made of thin walled stainless steel tubinghaving a wall thickness 235. However, other thin-walled metallic tubingcan also be suitable. For example, 15 gauge thin-walled tubing (having0.006 in. or 0.153 mm thick wall) provides sufficient rigidity toconstrain ventilation tube 215 in a compressed configuration. Inaddition, wall thickness 235 provides sufficient material to sharpeninto a cutting edge 209.

One important feature of cutting sheath 206 (and also positioning rod204) is the surface finish. The insertion system 200 can be operatedunder direct visualization by the user which requires sufficientlighting. In one embodiment, when used with an otoscope, operatingmicroscope, or fiber optic scope, a non-reflective surface finish canreduce the glare off cutting sheath 206 and positioning rod 204, whichwould hinder visualization. A non-glare surface finish can be achievedby abrasive blasting of the parts, surface passivation, oxidation, orother suitable surface treatment, which reduce or eliminate thereflective properties of materials of cutting sheath 206 and positioningrod 204. In another embodiment, the inner diameter of cutting sheath 206and/or the outer diameter of positioning rod 204 could be treated with alubricious coating, such as PTFE, to reduce the friction between the twosliding surfaces during sheath retraction while also providing anon-glare surface.

The slot 224 illustrated in FIGS. 9 and 12 allows a tab or visualizationtab 288 of ventilation tube 215 to be visible, or for a tab orvisualization tab 288 of ventilation tube 215 to extend outward throughcutting sheath 206 to provide a physical or visual indication of tube215 location for proper placement through the TM. As illustrated inFIGS. 7 and 8, slot 224 extends from distal end or cutting edge 209 toterminating end 225 and is substantially straight.

However, slot 224 is not limited to the configuration illustrated inFIG. 55. FIG. 57 illustrates a bottom view of another embodiment of acutting sheath 406, slot 424 can have a spiral twist, which could beused to impart a spin on a ventilation tube, such as ventilation tube215, to improve deployment across the TM. A slot 424 having a twist, orother non-straight geometry could also be used to position a tab on theventilation tube, such as visualization tab 288 of ventilation tube 215,closer to the longest edge of the cutting sheath (i.e., opposite wherethe slot 424 intersects with distal end or cutting edge 409) to allow auser to more easily visualize both the tab on the ventilation tube andthe longest edge of cutting edge 209 during use. Slot 424 can be formedusing a helix that has a pitch ranging between 0.5 inches (12.7 mm) and1.5 inches (35.1 mm). However, slot 424 can also be a simple curve.

FIG. 57 also illustrates cutting sheath 406 with an unsharpened cuttingedge or distal end 409, which allows an insertion system, to be used toinsert a ventilation tube into a pre-existing incision in the TM. Aprimary bevel of between approximately 40 and 60 degrees minimizes thelength of cutting sheath 406 that must be inserted into the middle earto properly position the ventilation tube across the TM. Since cuttingsheath 406 doesn't require sharpening, cutting sheath 406 could bemanufactured from plastic, such as PEEK, acrylic, poliamide, or suitablealternatives, and could be clear or translucent to allow the user tovisualize the ventilation tube loaded in cutting sheath 406. Inaddition, a light source internal to the positioning rod, for example afiber optic light source, could be used to illuminate a clear sheathfrom the inside, thus allowing a tertiary means of determining tubelocation within the sheath to aid in placement in the TM at the correctdepth.

FIG. 58 illustrates a bottom view of yet another embodiment of a cuttingsheath 506 with a modified geometry where slot 524 meets sharpeneddistal end or cutting edge 509. This modified geometry can be achievedduring the forming of slot 524, or during the sharpening process.Beveling, or softening the corners 536 where slot 524 meets thesharpened beveled face 538 of cutting sheath 506 solves two problems.First, it reduces the chances of tearing the TM or accidental ‘coring’out of a section of the TM and second, it improves the loadability ofventilation tubes if those tubes are inserted into the distal end 509 ofthe tube. Sharp corners or points created by slot 524 that is cutstraight into the beveled end of the sheath can catch, cut, or tearsilicone ventilation tubes during loading if not beveled or softened.

FIGS. 59-64 illustrate different embodiments of a cutting sheath with avisual indicator or physical stop so as to provide the user with theability to determine depth of penetration through the TM relative to thebevel located on the distal end of the cutting sheath. In FIGS. 59 and60 (where FIG. 59 illustrates a perspective view and FIG. 60 illustratesa side view), a visual indicator 1445 extends outward from cuttingsheath 1406 approximately 180 degrees from the top of cutting sheath1406 and opposite a slot (not illustrated), which is located at a bottomof cutting sheath 1406. In addition, visual indicator 1445 is positionedat the substantially same distance as the distance of the proximal endof the beveled portion (i.e., where the bevel portion begins) of cuttingsheath 1406. Visual indicator 1445 allows a user to visually determinethe degree of bevel penetration through the TM without being able to seethe actual beveled portion of cutting sheath 1406. Visual indicator 1445could also provide tactile feedback that the correct penetration depthhas been achieved by stopping further advancement of the sheath manuallythrough the TM. In FIGS. 61 and 62 (where FIG. 61 illustrates aperspective view and FIG. 62 illustrates a side view), a visualindicator 1545, which encompasses all or a portion of the outercircumference of cutting sheath 1506 and which is located such thatvisual or physical proximity to the TM indicates that a correct depth ofpenetration has been achieved such that the entire beveled portion ofthe sheath has penetrated the TM. FIGS. 63 and 64 (where FIG. 63illustrates a perspective view and FIG. 64 illustrates a side view)illustrates visual marker bands 1645 that may span all or a portion ofthe circumference of cutting sheath 1606 such that the user can visuallydetermine the locations of the beveled portion of the sheath or theproximal end of the ventilation tube, or both, from any viewing anglealong the positioning rod and sheath. In one embodiment, two visualmarker bands can be used to provide a range of acceptable TM locations(e.g., a max/min type indicator). Still further, the cutting sheath, thepositioning rod or both can be designed or constructed from materialsthat have echogenic properties, making it easier to visualize theirlocation using ultrasound in cases where visualization by physical meansis not feasible or is not sufficient.

FIG. 65 illustrates an enlarged view of an insertion end 1702 includingone embodiment of a visual indicator or physical stop 1745 provided by acutting sheath or other element 1751 (as is illustrated in FIG. 65)positioned on the outside or over cutting sheath 1706. As shown, cuttingsheath 1706 attaches to positioning rod 1704 (shown in phantom) suchthat the distal end of element 1751 and visual indicator 1745 arelocated at the same location as the proximal end of the beveled portionof cutting sheath 1706. In the embodiment, element 1751 is acircumferential sheath of which a portion is cut away to maintainvisibility of visual indicator 1745 and of a tab 1788 on ventilationtube 1715, which extends through the slot in cutting sheath 1706.Additionally, the attachment point of the circumferential sheath 1751 tocutting sheath 1706 is positioned such that the necessary coaxial motionof cutting sheath along positioning rod 1704 is not impeded bycircumferential sheath 1751. Circumferential sheath 1751 could alsoextend over the complete length of positioning rod 1704 and be attachedto the handle assembly or nose of the nose assembly. The samefunctionality as the functionality of circumferential sheath 1751 couldbe achieved with other elements, such as wires or partial sheaths whichwould extend along the sheath element to the beginning of the beveledportion of the cutting sheath.

FIG. 66 illustrates a side view and FIG. 67 illustrates a bottom view ofcutting sheath 1806 with a sensing element 1853 for detecting when thecutting sheath has penetrated sufficiently through the TM to allow fortube deployment. Inserting cutting sheath 1806 through the TM far enoughso that the lateral flange of the ventilation tube is past the TM at theshallowest point of penetration ensures successful tube placement.Because of the bevel on cutting sheath 1806, a heel 1855 of the bevelwill be the point where minimum penetration occurs, and as such, sensingwhen this point or a point just past this on the cutting sheath is incontact with the TM would allow the user to detect correct depth ofpenetration for tube deployment. A mechanical sensor to detect thephysical resistance created by direct contact with the TM, or anelectrical sensor to detect a change in electrical resistance viacontact with the TM can be employed. It should be understood that anysensing means capable of detecting contact or proximity could be used.Upon detection of a correct depth of penetration, the insertion devicecould generate a signal, such as an audible tone, to indicate to theuser that tube deployment can be performed. In another embodiment, theinsertion device may detect a correct depth of penetration through theTM and automatically retract the cutting sheath thereby deploying thetube and limiting an further penetration into the middle ear. In thisembodiment, the user manually advances the device through the TM untilthe sheath retracts automatically, and then applies suction if necessaryor removes the device from the ear canal.

FIG. 68 illustrates a side view of another embodiment of an insertionend 602. In FIG. 68, a passive safety sheath 637 is located over thecutting sheath 606 (shown in phantom). Safety sheath 637 can be held inplace by friction, and manually removed by the user immediately beforeuse. This safety sheath 637 protects the cutting edge 609 duringshipping, and protects the clinician from inadvertent needle sticks orcuts prior to use. Alternatively, safety sheath 637 can be manuallyretracted by the user immediately before use, exposing the cutting edge609 but remaining in place around positioning rod 604. After deploying aventilation tube across the TM, safety sheath 637 could then be movedback into its original position around cutting sheath 606, againprotecting users from inadvertent needle sticks.

FIG. 69 illustrates a side view of positioning rod 204. Positioning rod204 is a continuous hollow body including a bend 246 having an angle 216that divides positioning rod 204 into a first leg 247 and a second leg249. First leg 247 is greater in length than second leg 249 and includesdistal end 207, which is configured to abut against a ventilation tubewhen loaded in insertion system 200 and when being deployed. A proximalend 248 of second leg 249 engages with nose 213 (FIG. 2) of insertionsystem 200. The length of the short leg 249 extends through nose piece250 and between approximately 0.5 and 1.5 inches (i.e., 12.7 and 38.1mm). The function of short leg 249 is to move longer leg 247sufficiently far enough away from where nose 213 connects to handle 212(FIG. 2) to allow the user to maintain sight lines straight down leg247. The shorter leg 249 ensures that the user does not block thesesight lines with their fingers while grasping the front of handle 212.The length of longer leg 247 is between approximately 50 and 100 mm.More particularly, leg 247 is approximately 60-65 mm. This length issufficient to allow cutting sheath 206 to reach deep enough into the earcanal and the middle ear for a ventilation tube to be positioned anddeployed across the TM. The radius of the bend 246 in positioning rod204 can range between approximately 0.25 and 2 inches (i.e., 6.35 and50.8 mm). More particularly, the radius of bend 246 can be betweenapproximately 0.4 and 0.8 inches (i.e., 10.16 and 20.32 mm). The bend246 in positioning rod 204 should be minimized so that the radiusportion does not interfere with the a speculum (which will be discussedin detail below) or other interfacing accessories, while being keptlarge enough such that it allows the sliding of the actuation member 214along its inner lumen without imposing excessive frictional restrainingforces. In a spring-loaded design, where a spring is chosen to set theresistive force, a large radius for the positioning rod to minimizeresistance could be used.

FIGS. 70-73 illustrate enlarged views of various embodiments of a distalend of a positioning rod. FIG. 70 illustrates an enlarged view of distalend 207 of positioning rod 204. Positioning rod 204 includes a straightslot or channel 222 formed into positioning rod 204 and intersectingwith distal end 207 and extending to a terminating area 239. Aspreviously described, channel 222 provides a passage for actuationmember 214 to transition from the inside of positioning rod 204 to anattachment point on the corresponding cutting sheath 206. In addition, alength 223 of channel 222 provides a range of motion for actuationmember 214, and can limit the maximum range of motion of cutting sheath206. Furthermore, channel 222 registers cutting sheath 206 topositioning rod 204. In particular, the angular orientation of cuttingsheath 206 is registered relative to positioning rod 204.

FIG. 71 is an enlarged view of an alternative embodiment of a distal endof a positioning rod. Like channel 222, a channel 722 formed in apositioning rod 704 is straight. However, rather than channel 722intersecting with distal end 207, as is the case in FIG. 70, channel 722extends from a distal area 741 that does not intersect with distal end707 to a terminating area 739. The embodiment illustrated in FIG. 71provides a full circular contact area at the end of positioning rod 704for positioning against a ventilation tube when a cutting sheath isbeing retracted during deployment of a ventilation tube.

FIG. 72 is an enlarged view of another alternative embodiment of adistal end of a positioning rod. FIG. 72 illustrates an embodiment wherechannel 822 includes a straight portion 842 and a j-shaped portion 843.Like channel 222, straight portion 842 of channel 822 intersects withdistal end 807 and extends to a terminating area 839. J-shaped portion843, however, extends as an arcuate slot from terminating area 839 toarcuate end 844. J-shaped portion 843 is configured to capture theactuation member after a ventilation tube is deployed, and preventingthe cutting sheath from being displaced forward again towards the TM. Incases where the cutting sheath is retracted sufficiently such that thecutting edge is positioned directly over positioning rod 804 andproximal to distal end 807, positioning rod 804 acts as a safetymechanism which protects the cutting edge of the cutting sheath toprevent accidental needle sticks. Additionally, because positioning rod804 cannot be returned to a pre-use state, the embodiment illustrated inFIG. 72 can also prevent the re-use of an insertion end when theinsertion end is intended to be a single-use device. While a J-shapedportion 843 of channel 822 is shown, other geometries which achieve thesame functionality are also considered.

For example, FIG. 73 illustrates an enlarged view of an embodiment wherechannel 922 of a positioning rod 904 intersects with distal end 907 ofpositioning rod 904 and extending to a terminating area 939. Unlikechannels 222, 722 and 822, channel 922 includes a helical or curvedpathway. The helical or curved pathway of channel 922 aids in insertinga ventilation tube into an insertion end by slightly rotating thecutting sheath as it is retracted along positioning rod 904. A helicalpathway can be formed using a helix that has a pitch betweenapproximately 0.5 inches (12.7 mm) and 1.5 inches (38.7 mm). It shouldbe understood that any combination of the preceding elements describedin FIGS. 70-73 regarding channels in a positioning rod can be used.

FIGS. 74-75 illustrate perspective views of various embodiments ofpositioning rods that include an interface for receiving an attachmentof or positioning of other devices alongside it such that the user canmove and position an attached device and the positioning rod with asingle hand. The embodiment illustrated in FIG. 74 shows a positioningrod 1004 having a clip 1052 located on the outer surface of the longerleg 1047. For example, clip 1052 can receive a fiber optic scope, afiber optic light source, drug delivery tubes, devices, or an atomizeror other type of peripheral attachment for enhancing the capabilities ofthe insertion system. The embodiment illustrated in FIG. 75 shows apositioning rod 1104 having a protuberance 1152 located on the outersurface of the longer leg 1147. For example, protuberance 1153 caninterface with a speculum (which will be discussed in detail below) orother interfacing accessories.

FIG. 76 illustrates an end view of insertion end 202 (with nose 213removed) illustrating the relationship between cutting sheath 206 andpositioning rod 204 in a first position or a position A. As illustratedin FIGS. 50-52 and 55-56 cutting sheath 206 is beveled and therefore hasone side that is longer in axial length than the other. In addition,slot 224 is cut along one side of cutting sheath 206. In one embodiment,slot 224 is formed along the shorter axial length side rather than thelonger axial length side of cutting sheath 206. Because of thesefeatures, cutting sheath 206 can be oriented in different angularrelationships to the bend 246 in positioning rod 204. In one embodiment,the long edge, or the leading point of cutting sheath 206 is locatedalong the top of bend 246 and slot 224 is located along the bottom ofbend 246 as shown in FIG. 76. However, the long edge and therefore slot224 on the sheath could be located at various angular relations to thebend 246 in positioning rod 204 to improve visualization under differentscenarios. For example, the long edge of cutting sheath 206 could bepositioned approximately 180 degrees from the top of the bend 246 ofpositioning rod 204 as indicated by a second position or a position B,or at any angle in between, such as approximately 45 degrees asindicated by a third position or a position C or approximately 90degrees as indicated by a fourth position or a position D.

As previously discussed and with reference back to FIG. 50, actuationmember 214 of insertion system 200 passes through channel 222 inpositioning rod 204 to attach to cutting sheath 206. In FIG. 50,actuation member can consist of a round, stainless steel wire with aspring temper or a soft temper that has a diameter of about 0.014 inchesor 0.3556 mm. A round cross section allows actuation member 214 tointerface with a round plug hole in cutting sheath 206 for ease ofmanufacturing and for making an attachment such as a weld or a brazebetween cutting sheath 206 and actuation member 214. The spring temperhelps prevent bends from setting during handling, manufacturing andassembly. In the alternative, a smaller diameter actuation member canalso be used, such as a diameter of about 0.009 inches or 0.2286 mm, toreduce friction inside the positioning rod. By keeping actuation member214 consistently straight, or with a known bend profile, the frictionalforce of actuation member 214 contacting the internal lumen ofpositioning rod 204 is kept consistent and provides for a consistentdegree of resistance during cutting sheath 206 retraction. Actuationmember 214 can also include a lubricious coating, such as PTFE, tominimize the frictional force of actuation member 214 sliding insidepositioning rod 204. In an alternative embodiment, actuation member 214can consist of flat wire. Flat wire can provide a greater surface areaand potentially improved interface geometry where actuation member 214attaches to cutting sheath 206 or to actuator mechanism 210 in handle212.

FIG. 77 is a side view of an actuation member 1214 that illustratesalternative embodiments to actuation member 214 illustrated in FIG. 50.In one embodiment, actuation member 1214 includes one or more bends 1254along its length which can increase or decrease the frictional forcethat actuation member 1214 experiences sliding along the internal lumenof a positioning rod during cutting sheath retraction. Bend 1254 aillustrates a bend in a shape closely approximating the bend in apositioning rod, which eliminates most of the friction encounteredduring initial retraction of the cutting sheath, allowing for an easierstart to the retraction process. Bends 1254 b, c and d show actuationmember 1214 with one or more bends intended to increase the frictionalforce between actuation member 1214 and a positioning rod. Increasingthe force between actuation member 1214 and a positioning rod can beuseful for holding the cutting sheath in the retracted position after aventilation tube has been deployed and preventing unwanted sheathretraction during shipping and handling prior to use. Bends 1254 a, band c can also provide repeatable resistive force during the entirecutting sheath retraction process, and prevent inadvertent ‘jumping’ ofthe ventilation tube out of the cutting sheath when the ventilation tubeis partially or fully deployed. If the frictional force of theventilation tube against the inner lumen of the cutting sheath is thegoverning resistance to sheath retraction, the resisting force willchange as the ventilation tube is deployed and the contact surface areais reduced, and may change in a stepwise function as flanges on theventilation tube are deployed. Using the frictional resistance to motionof the actuation member can moderate this.

It should be noted that in another alternative embodiment, an actuationmember could be routed completely outside of the positioning rod ratherthan partially inside the positioning rod and therefore positioning rod204 need not be hollow. In such an embodiment, the actuation memberexits the handle, such as handle 212, of the insertion system, such asinsertion system 200, and travels along the outside of the positioningrod and attaches to a proximal end of the cutting sheath or anywherealong the length of the cutting sheath. Guide tubes or tabs locatedalong the outer diameter of the positioning rod could be used to routeand constrain the actuation member. In one embodiment, the actuationmember could pass through an aperture or slot in the cutting sheath andprotrude into the inner lumen of the positioning rod to thus allow theactuation member to act as a registration mechanism to register thesheath to a slot or aperture located on the positioning rod.

The attachment between an actuation member and a cutting sheath does notneed to be permanent. In such an embodiment, the actuation member mayinclude a shorter bent portion on its end that engages reversibly withan aperture in the sheath. A larger bend or ‘bow’ in the actuationmember ensures that the shorter bent portion remains pushed against theinner diameter of the cutting sheath such that at least a portion of thebent section remains engaged with the cutting sheath aperture. Thisembodiment allows the user to push the actuation member back into or outof the aperture on the cutting sheath, making the cutting sheathremovable and/or replaceable. In instances where a bilateral ventilationtube placement is warranted, two cutting sheathes with pre-loadedventilation tubes could be provided, and the clinician could attach themto a single insertion handle to reduce waste.

Besides nose assembly 203 including cutting sheath 206, positioning rod204 and actuation member 214, nose assembly 203 also includes nose 213,which is illustrated in an enlarged exploded view in FIG. 78 and in anenlarged assembled view in FIG. 79. In regards to insertion system 200′,FIG. 80 illustrates an enlarged exploded view of nose 213′. Nose 213 or213′ includes an actuating mechanism interface component or pull 256 or256′, a suction interface component or drain 258 and a nose piece 260.In regards to the insertion system 200 embodiment, drain 258 and nosepiece 260 are two separate components. In regards to the insertionsystem 200′ embodiment, drain 258 and nose piece 260 are integral andlabeled as drain-nose piece 260′. In other embodiments, drain 258 andnose piece 260 can be overmolded directly onto positioning rod 204 toensure correct orientation and sufficient bond. Regardless, the use of asuitable high viscosity lubricant, such as silicone grease, can be usedbetween pull 256′ and drain-nose piece 260′ to eliminate gaps which cancause suction loss without negatively impacting the friction betweenthose parts.

From positioning rod 204 (not illustrated in FIG. 78 or 79), actuationmember 214 (illustrated in FIG. 78) attaches to actuating mechanisminterface or pull 256 or 256′ along central axis 261 or 261′ throughnose piece 260 and suction interface component or drain 258 ordrain-nose piece 260′. In this embodiment, a fastener 259, such as athreaded set screw (FIGS. 78 and 79), can be used to hold actuatingmember 214 against an internal face of pull 256 or 256′. In FIGS. 78 and79, the threaded set screw is advanced through pull 256 in a directionsubstantially perpendicular to central axis 261 and tightened down Inother embodiments, such as the embodiment illustrated in FIG. 80,actuating member 214 can be held against internal face of pull 256 or256's using an adhesive and then trimmed off. Eliminating a hole in pull256 or 256′ for receiving a fastener or other mechanical fastener wouldultimately prevent suction loss. However, assembling actuating member214 to pull 256 or 256′ becomes more difficult. To eliminate the holeand in one embodiment, a mechanical gripping feature, for example aone-way cam gripper, could be over-molded into pull 256 or 256′ suchthat actuating member 214 is advanced through to the correct positionduring assembly and automatically locks in place.

As illustrated in FIGS. 78 and 80, an aperture in the distal end of pull256 and 256′ allows actuating member or wire 214 to pass through. InFIG. 80, the aperture is smaller than the aperture in FIG. 78. A smallerhole prevents suction loss when insertion system 200′ undergoes asuction functionality. Further, actuating member or wire 214 ismechanically sealed in the aperture with, for example, adhesive, toprevent even further suction loss when insertion system 200′ undergoes asuction functionality. Positioning rod 204 (again not illustrated inFIG. 78 or 79) attaches to suction interface component or drain 258 ordrain-nose piece 260′ along central axis 261 or 261′ through nose piece260. In particular, proximal end 248 (FIG. 69) of positioning rod 204traverses only a partial length of drain 258 or drain-nose piece 260′.

Drain 258 or drain-nose piece 260′ includes one or more suctionapertures 264 or 264′ (of which only one is illustrated in FIGS. 78 and79 and of which there is only a single suction aperture in FIG. 80). Inthe embodiments illustrated in FIGS. 78 and 80, suction apertures 264 or264′ are square in shape. However, any shape is possible. Drain 258 ordrain-nose piece 260′ may also include a suction block to redirect fluidtraveling along axis 261 or 261′ through suction apertures 264 or 264′and into a fluid channel in the main body of the handle assembly 205 or205′. In FIG. 78, fastener 259 or an adhesive fastener not onlyfunctions as a device for fastening actuation member 214 in place, butalso acts as the suction block. In another embodiment, though notillustrated, a suction block can include a thin polymer washer with asmall hole or slit cut through it to allow the actuation member 214 topass through, but still allow actuation member 214 to closely conform todrain 258, thus blocking off any suction losses. In one embodiment, asuction block includes a polyurethane rubber washer with a radial slitextending halfway across the circular face. The physical properties ofthe suction block, along with the geometry, can be modified to increaseor decrease the frictional resistance the actuating member 214experiences passing through it. Similar to the bends that can be made inactuation member 214 to increase or decrease drag inside positioning rod204, the aperture size in the suction block, its frictional properties,and its thickness can all be changed to increase or decrease drag on theactuation member 214.

Nose piece 260 or drain-nose piece 260′ includes a tab 262 or 262′ whichinterfaces or engages with a stop component 296 or 296′ on the handleassembly 205 or 205′. Tab 262 or 262′ provides a visual as well asfunctional means of registering nose assembly 203 or 203′ with handleassembly 205 or 205′ to achieve desired positioning relative to eachother as well as to allow nose assembly 203 or 203′ and handle assembly205 or 205′ to assemble or disassemble (connect or disconnect). Detailsregarding the connection between nose assembly 203 or 203′ and handleassembly 205 or 205′ will be discussed in detail below.

FIG. 81 illustrates a partial perspective cut-away view of handleassembly 205 of insertion system 200 and FIG. 83 illustrates a sectionview of main body 263 of handle assembly 205 of insertion system 200.Handle assembly 205 includes main body 263, nose interface 217 forinterfacing with nose assembly 203, a rotatable actuating element orscroll wheel 210, a rack 267 and one or more drive gears 268 couplingthe rotatable actuating element or scroll wheel 210 to rack 267.

As illustrated in FIG. 83, main body 263 includes a primary fluidchannel 270, a secondary fluid channel 271 and one or more suction weepholes 272. The proximal end of main body 263 of handle assembly 205includes an area for receiving a fitting for coupling main body 263 to asource of negative pressure. For example, FIGS. 2 and 3, illustrate thedistal end of handle assembly 205 as including a barbed fitting 273.

Suction, as provided by the suction source, passes through the primaryand secondary fluid channels 270 and 271 inside main body 263 of handleassembly 205. Primary fluid channel 270 is in fluid communicationthrough apertures 264 in drain 258 and down the positioning rod 204 tocutting edge 209 of cutting sheath 206. Secondary fluid channel 271branches off primary fluid channel 270 and is in communication with theone more weep holes 272. Weep holes 272 provide the control fordelivering suction to distal end 207 (FIGS. 50 and 65) of thepositioning rod 204. In one embodiment, a plug, adhesive patch, or othersuitable component can be used to block off one of the two weep holes.The user is able to cover the remaining weep hole as desired to directthe application of negative pressure to distal end 207 of positioningrod 204 or insertion end 202. Handle assembly 205 can be provided with arepositionable component, such as a flexible polymer plug orrepositionable adhesive patch, for plugging one of the weep holes. Therepositionable component can be left in place or removed as desired bythe user. In an alternative embodiment, both weep holes 272 could beplugged initially, and the user could remove the plug over the weep holeof their choice prior to use.

With reference to FIG. 83 and in one embodiment, primary fluid channel270 of main body 263 provides a fluid path 274 that communicates betweenthe suction source (i.e., the barbed fitting 273) and distal end 207 ofpositioning rod 204. Secondary fluid channel 271 branches off primarychannel 270 and provides a fluid path 275 that communicates with theweep holes 272. By placing secondary fluid channel 271 above primaryfluid channel 270 and making the intersection of second fluid channel271 with primary fluid channel 272 such that fluid path 275 is at anacute angle to fluid path 274, the possibility of aspirated fluidspassing down secondary channel 271 and out of weep holes 272 iseliminated or reduced.

While the weep holes 272 are positioned along the lateral edges of mainbody 263 of handle assembly 205, it should be understood that they couldbe located on the top and/or bottom of main body 263 as well, and thatwhile barbed fitting 273 is oriented along a central axis of main body263, it could be located along the length of main body 263 at an anglethat is not parallel to the central axis of the main body.

It is possible for suction traveling through main body 263 to generatenoise which can be transmitted into the ear canal even when the weepholes 272 are not blocked and suction is not being provided to distalend 207 of positioning rod 204, and this noise can be disturbing to thepatient. To prevent painful noise, a valve or shutoff can be locatedbetween the barbed fitting 273 and weep holes 272 such that negativepressure is still present, but the air flow that generates the noise isprevented.

Nose interface 217 is positioned at a distal end of handle assembly 205and includes a stop component 296. Stop component 296 includes arecessed area that is recessed into nose interface 217 and partiallyextends around a peripheral area of nose interface 217. The recessedarea includes a shelf portion 265 (illustrated in FIGS. 2 and 3) locatedat one end of the recessed area and a plurality of spaced apart detents269 (FIG. 81) extending across the remaining of the recessed area.

To physically attach nose assembly 203 to handle assembly 205, tab 262on nose piece 260 of nose assembly 203 engages with shelf portion 265.At the same time, a collar 276 (FIGS. 78 and 79) on pull 256 mates withone or more protrusions 277, such as a pair of protrusions, on rack 267of handle assembly 205. FIG. 85 illustrates an enlarged perspective viewof nose 213 and rack 267 before they mate together. More specifically,collar 276 includes a pair of opposing slots 278. When nose piece 260 ispushed onto shelf portion 265 of nose interface 217, collar 276 slidesthrough protrusions 277 by way of slots 278 and is positioned on aninternal side of protrusions 277. Tab 262 is then rotated from shelfportion 265 to engage with a select detent of the plurality of detents269. Which of the detents is selected depends on the desired position orangle of nose assembly 203 relative to handle assembly 205. When tab 262is rotated, collar 276 also mates with protrusions 277 so that pull 256cannot move out of position. In other words, once nose assembly 203 andhandle assembly 205 are pushed together, rotating them with respect toone another results in tab 262 engaging with a select detent of theplurality of detents 269 and protrusions 277 on the rack 267 turninginto a groove 279 on pull 256.

Therefore, tab 262 provides a physical means of limiting the degree orrotation between nose assembly 203 and handle assembly 205. In addition,tab 262 interfaces with the number of detents 269 on handle assembly205, which provide positive stops over the range of rotationaladjustability between the nose and handle assemblies 203 and 205. Theuser is able to manually twist nose assembly 203 in relation to handleassembly 205 to achieve the best orientation to achieve ventilation tubeplacement, while the positive stops provide sufficient resistance tomovement so that nose 213 does not inadvertently rotate during tubeinsertion. In addition, by engaging tab 262 with stop component 296,fluid path 274 through handle assembly 203 and positioning rod 204 iscompleted. While detents 269 are illustrated, other means of providingfrictional resistance to rotation between nose assembly 203 and stopcomponent 296 could be used. For example, merely providing a contactresistance between tab 262 and nose interface 217 of handle assembly 205is sufficient.

Shelf portion 265 allows for ease of assembly of nose assembly 203 andhandle assembly 205 including rotating tab 262 of nose 213 into thedetents 269. However, disassembling nose assembly 203 from handleassembly 205 requires increased force to rotate tab 262 of nose 213 backonto shelf portion 265. Tab 262 being located on shelf portion 265 isthe requisite position needed to assemble and disassemble nose assembly203 to handle assembly 205. This feature prevents the user fromaccidentally adjusting the rotational orientation of the two assembliesso far that the rack 267 and pull 256 are not connected, and thereforenose 213 cannot inadvertently fall off.

FIG. 82 illustrates a partial perspective view of handle assembly 205′assembled to nose 213′ of insertion system 200′ and FIG. 84 illustratesa section view of main body 263′ of handle assembly 205′ and nose 213′of insertion system 200′. Handle assembly 205′ includes main body 263′and nose 213′. As illustrated in FIG. 84, main body 263′ includes aprimary fluid channel 270′ and a suction weep hole 272′. Weep hole 272′is located on an upper surface of main body 263′. The proximal end ofmain body 263′ of handle assembly 205′ includes fitting 273′. Fitting273′ can comprise soft flexible tubing so as to eliminate transferringany torque or twist created by a vacuum line to handle assembly 205′.

Suction, as provided by the suction source, passes through the primaryfluid channel 270′ inside main body 263′ of handle assembly 205′.Primary fluid channel 270′ can be defined by polymer tubing, a t-fittingand a soft polymer double sealed component, which seals around nose213′. This sealing component goes around nose 213′ and allows forreplaceable noses while forming a seal and allows for rotation of thenose without breaking the seal. For example, the sealing component canbe made of PVC, urethane, silicone or the like. Primary fluid channel270′ is in fluid communication through aperture 264′ in drain-nose piece260′ and down the positioning rod to the cutting edge of the cuttingsheath and is also in communication with weep hole 272′. Weep hole 272′provides the control for delivering suction to a distal end 207 of thepositioning rod. In this embodiment, suction is available regardless ofthe position of scroll wheel 210′ (FIGS. 4 and 5), the cutting sheath orpull 256′ (FIG. 80).

Nose 213′ is positioned at a distal end of handle assembly 205′ andincludes a stop component 296′. Stop component 296′ includes a recessedarea that is recessed into a nose interface 217 and partially extendsaround a peripheral area of nose interface 217′. The recessed areaincludes a shelf portion 265′ located at one end of the recessed areaand a plurality of spaced apart detents 269′ (of which only one isvisible in FIG. 82) extending across or about the recessed area. Likeshelf portion 265, shelf portion 265′ engages with tab 262′ when nose213′ is initially attached to handle 212′. As illustrated, stopcomponent 296′ includes three spaced apart detents. Each detentrepresents a locking point where tab 262′ can be engaged when nose 213′is rotated for operation.

Although not specifically illustrated in FIGS. 4 and 5, FIG. 82illustrates a plurality of visual markers located at a distal end ofhandle assembly 205′. In particular, handle assembly 205′ can include aninsertion marker 294′ and stop markers 295′. Insertion marker 294′corresponds with shelf portion 265′ and is in the shape of a triangle.In this way, a clinician can easily ascertain where a tab 262′ needs toalign with and engage with stop component 296′ for the insertion orremoval of handle 212′. Each stop marker 295′ corresponds with a detent269′ and is in the shape of a dash. In this way, a clinician can easilyascertain the different rotational adjustments that tab 262′ can make toadjust the alignment of nose assembly 203′.

To physically attach nose assembly 203′ to handle assembly 205′, tab262′ on drain-nose piece 260′ of nose assembly 203′ engages with stopcomponent 296′. At the same time, a collar 276′ (FIG. 80) on pull 256′mates with component in handle assembly 205′ to provide a zero insertionforce. Tab 262′ is then rotated from the shelf portion in a cam actionto tighten nose 213′ and engage tab 262′ with a select detent of theplurality of detents 269. Which of the detents is selected depends onthe desired position or angle of nose assembly 203′ relative to handleassembly 205′.

Therefore, tab 262′ provides a physical means of limiting the degree orrotation between nose assembly 203′ and handle assembly 205′. Inaddition, tab 262′ interfaces with the number of detents 269′ on handleassembly 205′, which provide positive stops over the range of rotationaladjustability between the nose and handle assemblies 203′ and 205′. Tab262′ also includes a flange 297′ to push during rotational adjustment.Further, nose 213′ includes at least one circumferential rib or boss299′ (FIG. 82 illustrate a plurality of ribs or bosses 299′) to providea grip feature for the push or pull or insertion or removal of nose213′.

After assembly of nose assembly 203 or 203′ and handle assembly 205 or205′, axial movement of rack 267 along a central axis 261 results in acorresponding movement of pull 256 o 256′, actuation member 214, andtherefore cutting sheath 206. As previously described, rack 267 iscoupled to actuating element or scroll wheel 210 or 210′ through the oneor more drive gears 268. Therefore, a user can rotate rotatableactuating element or scroll wheel 210 or 210′ in a direction 227 (FIG.81) from a first position (shown in FIGS. 2, 3, 4 and 5), which is aforward position located toward stop component 296 or 296′, to a secondposition, which is a backward position located toward fitting 273 or273′, to move cutting sheath 206. More specifically, clockwise rotationor backwards rotation of scroll wheel 210 or 210′ retracts cuttingsheath 206 and therefore deploys ventilation tube 215 since cuttingsheath 206 is the element to which ventilation tube 215 is beingconstrained. While it is possible for scroll wheel 210 or 210′ to rotateforwards to deploy a ventilation tube, inadvertent movement imparted tothe handle during such a rotation would result in a deeper penetrationof the cutting sheath behind the patient and toward the user is a safetyfeature.

Scroll wheel 210 or 210′ can further comprise a physical feature or bump231 or 231′ to provide physical feedback to the user. For example, bump231 or′231′ located on the outer surface of scroll wheel 210 or 231′ canbe a secondary material overmolded onto scroll wheel 210 or 210′ toprovide better friction between the user and scroll wheel 210. Inparticular, bump 231 or 231′ can have a width that is larger than awidth of scroll wheel 210 or 210′ to allow a slight mechanical advantageto the user by providing a longer lever arm about the axis of rotation.Because many ventilation tube placement operations are performed throughan operating microscope, it is common for surgeons to be handedinstruments ‘blindly’, and they must be able to orient the device intheir hand by feel instead of visually. Bump 231 or 231′ shown on scrollwheel 210 or 210′ in FIGS. 2, 3, 4, 5 and 87 allows the clinician tofeel where scroll wheel 210 or 210′ is before and during actuation.

The location of scroll wheel 210 or 210′ as illustrated in FIGS. 2, 3, 4and 5 allows insertion system 200 or 200′ to be actuated using a thumbor a forefinger, and in combination with the rotational adjustability ofnose assembly 203 or 203′ and dual weep holes 272 or single weep hole272′ allows insertion system 200 or 200′ to be used in a right-handed orleft-handed orientation. When using the thumb to actuate scroll wheel210, an index finger is used to cover one of the weep holes 272. Whenusing the index finger to actuate scroll wheel 210, the thumb is used tocontrol suction by covering one of the weep holes 272. The location ofthe single weep hole 272′ on insertion system 200′ eliminates the needfor a means of plugging the unused weep hole. The same digit used toactuate scroll wheel 210′ is also used to cover weep hole 272′ to applysuction. The symmetrical location of weep hole 272′, combined with it'sproximity to scroll wheel 210′ reduces the amount of hand movementrequired between the steps of actuation and suction application, andallows the user to employ the same digit to achieve both functions.

As also illustrated in FIG. 81 and as previously discussed, the one ormore drive gears 268, which allow the rotational motion of scroll wheel210 to be translated into linear motion for retracting cutting sheathelement 206, includes at least a scroll gear 268 a and a reversing gear268 b. The use of a sequence of gears as shown allows for a change indirection between scroll gear 268 a and scroll wheel 210. In addition,the use of a sequence of gears allows for a gearing up or down toachieve different mechanical advantages. For example, scroll wheel 210may rotate through a greater or lesser angle than the final drive gear.

FIG. 86 illustrates a flexible polymer ventilation tube, such as T-tube515 a of FIG. 37, being radially loaded into cutting sheath 206. Using amandrel 1331 inserted into the inner lumen of ventilation tube 515 a,the ventilation tube 515 a is positioned proximal to slot 224, and thenforced through the slot 224 and down into the inner lumen of cuttingsheath 206. While T-tube 515 a is shown in FIG. 29, it should berealized that other types of tubes can be used including grommet typetubes.

FIG. 87 illustrates a flexible polymer ventilation tube, such as grommettube 315 b of FIG. 7, being axially loaded into cutting sheath 206.Cutting sheath 206 is inserted into a snug loading tube 1341 (forexample a clear or translucent polymer tube) such that the beveleddistal end of cutting sheath 206 is inside loading tube 1341. A flexiblefilament 1343, such as a string or nylon monofilament, is passed throughcutting sheath 206 such that a closed loop extends past the beveleddistal end of cutting sheath 206 and out of the loading tube 1341 whilethe free ends extend out the proximal, unbeveled end of cutting sheath206. A flexible polymer ventilation tube, for example a siliconePaparella style such as tube 315 b, is passed through the loop infilament loop, and the loop is tightened down around the middle of thetube body. By holding onto the medial flange 384 b of ventilation tube315 b while pulling on filament 1343, the tube 315 b is pulled into thepolymer tube with the lateral flange 386 b entering first. Withventilation tube 315 b pulled completely into loading tube 1341, theventilation tube 315 b can be rotated within cutting sheath 206 to alignany tabs or flanges, such as tab 388 b, on ventilation tube 315 b withthe slot 224 in cutting sheath 206. Ventilation tube 315 b is thenpulled into cutting sheath 206 with filament 1343. When ventilation tube315 b is positioned correctly in cutting sheath 206, one free end offilament 1343 is pulled while the other end is allowed to pull intocutting sheath 206 and around ventilation tube 315 b so that it can beremoved from around the ventilation tube and from inside cutting sheath206. The loading tube 1341 can then be removed from cutting sheath 206,or it can be left in place to protect the cutting edge if the beveleddistal end of cutting sheath 206 is sharpened.

In this loading method, a lancet style grind ensures that any cuttingedges on the beveled portion of the sheath are located flush against theinner diameter of the loading tube, minimizing the chance that they willcatch on or cut the ventilation tube during loading. A back grind on thecutting sheath would position the cutting edges on the inner diameter ofthe cutting sheath, which would be spaced away from the wall of aloading tube and could catch on or cut a flexible ventilation tubeduring the loading process.

As shown in FIG. 87, the loading tube 1341 may be circular along itsentire length, or may match the outer geometry of the sheath. In anotherembodiment, loading tube 1341 may transition from an oval shape at adistal end to a circular shape where the distal end of the cuttingsheath is positioned as shown in FIG. 88. An oval shape at the distalend of the loading tube where the ventilation tube is inserted helpsensure the medial and lateral flanges of the ventilation tube fold downin a repeatable fashion. Because medial and lateral flanges on aventilation tube may be fully circumferential, and the cutting sheathhas a slot, it is important to fold the medial and lateral flanges downsuch that they don't protrude through the slot, but that any tabs thatare intended to protrude through the slot are positioned correctly suchthat they remain protruding.

FIG. 89 illustrates an alternative embodiment for a ventilation tube3215 for axially loading into a cutting sheath. As described above,holes, or other features may be included on the ventilation tube'slateral flange or tabs that make it easier to load the ventilation tube.For example, a ventilation tube could have one or more holes 3217 in thelateral flange 3286 that a filament is passed through during loadingthat allows it to be pulled into the cutting sheath. Such a filamentcould then be removed before use, or could be left in place as a safetyelement which could be used to grasp the ventilation tube in cases whereit may inadvertently fall into the inner ear during insertion.

The ability to remove a nose assembly from a handle assembly of aninsertion system makes it easier to load ventilation tubes duringmanufacturing by enabling access to a proximal end of a positioning rod.In this way, it is possible to use a pulling filament to loadventilation tubes axially into the distal end of the cutting sheath. Byusing a removable attachment (such as a set screw) to anchor theactuating wire inside the nose assembly, the ventilation tube can beloaded before the cutting sheath is assembled onto the positioning rod.

The ventilation tube can also be loaded after the nose assembly and thehandle assembly are fully assembled. The pulling filament can be fedthrough a loading tube and through the slot in the cutting sheath suchthat the ventilation tube can be pulled into the sheath without accessto the proximal end of the cutting sheath for insertion of the pullingfilament.

Loading methods that pull the ventilation tube into position by graspingit behind the lateral flange are preferred because they result in theproximal flange folding up and away from the main body of theventilation tube and the distal flange folding down and away from themain body of the ventilation tube as well as potentially providing aslight stretch to the main body of the tube. This is desirable, becausesuch a configuration increases the spacing between the lateral andmedial flanges on the ventilation tube, which makes it easier toposition the ventilation tube across the TM. Loading methods that pushthe ventilation tube axially into the distal end of the cutting sheathmay result in the lateral flange of the ventilation tube folding downand toward the main body of the tube.

FIG. 90 illustrates a flow chart 3300 describing a manual process forinserting a ventilation tube 215 into a TM of the body using insertionsystem 200. At block 3302, ventilation tube 215 is loaded into cuttingsheath 206. At block 3304, nose assembly 203 is assembled to handleassembly 205 by interlocking nose 213 with stop component 264. It shouldbe realized, however, that blocks 3302 and 3304 can be performed in thereverse order as well. Such loading procedures are illustrated anddiscussed in regards to FIGS. 86-89. At block 3306, insertion end 202 ismanually advanced through a body, for example the outer ear, such thatdistal end 209 of cutting sheath 206 pierces through a membrane, such asa TM. As discussed above, how far to insert insertion end 202 or distalend 209 of cutting sheath 206 into the TM is determined by a visual orphysical indicators located at insertion end 202. In one embodiment, avisual indicator can be a tab 288 located on ventilation tube 215 thatis protruding through a slot 224 in cutting sheath 206. Other oradditional visual or physical indicators can be located on the outersurface of cutting sheath 206 including sensing elements as described indetail above. After insertion end 202 is inserted through the TM,cutting sheath 206 retraction is accomplished by rotating rotatableactuating element 210 on the handle assembly 205 from a first positionto a second position (i.e., in a direction toward the user of theinsertion system 200) as described in block 3308. This movement causescutting sheath 206 to fully retract from the TM. Removal of insertionend is then performed at block 3310 by removing insertion end 202 andtherefore insertion system 200 out of the body or outer ear.

FIG. 91 illustrates a flow chart 3400 describing a semi-automatedprocess for inserting a ventilation tube into a TM of the body using aninsertion system. At block 3402, an insertion end is manually advancedthrough an outer ear such that a distal end of a cutting sheath piercesthrough the TM as described at block 3404 and the ventilation tube islocated across the TM as described in block 3406. As discussed above,how far to insert insertion end 202 or distal end of cutting sheath intothe TM is determined by a visual or physical indicator. After theinsertion end is inserted through the TM, a deployment mechanism isactuated at block 3408. Actuation of the deployment mechanism providesfor the automatic retraction of the cutting sheath as described in block3410 and therefore the automated deployment of a ventilation tube asdescribed at block 3412. The automated retraction causes cutting sheath206 to fully retract from the TM as described in block 3414. At block3416, suction can be optionally applied and at block 3418 the insertionsystem is manually removed from the ear canal.

FIG. 92 illustrates an embodiment of an insertion system 3500 comprisingelements which facilitate the semi-automated placement of ventilationtubes as described above in FIG. 91. Shown is a spring 3555, whichautomatically retracts the cutting sheath when a deployment mechanism isdepressed. In FIG. 33, spring 3555 is configured to pull back onrotatable element or scroll wheel 3510. Also shown are an optionaldamper 3557 to slow the cutting sheath retraction to a controlled rate,and a shock absorber 3559, which stops the range of motion of theretraction. Both damper 3557 and shock absorber 3559 by themselves orworking in combination can decrease the noise generated by insertionsystem 3500 during deployment, reducing the noxious stimuli which maycause a patient to move upon ventilation tube deployment. Damper 3557also allows for the use of an oversized spring 3555 to provide more thansufficient actuation force without a comparable increase in the speed ofthe cutting sheath retraction or the noise generated by the retractionmechanism during motion or at the end of its range of motion.

FIG. 93 illustrates yet another embodiment of an insertion system 3600comprising a removable element 3649 that can be slid onto the cuttingsheath (hidden from view in FIG. 93) such that the cutting sheath iscovered and protected. The removable covering element 3649 can alsoinclude a means for the application of a topical anesthetic or othermedication to the ear canal or TM. Shown is a loop 3651 that could beused to apply an anesthetic, such as phenol, to the TM. Afterapplication of the anesthetic, the covering element 3649 can be removedsuch that the cutting sheath is exposed and can be used to implant aventilation tube. The removable element 3649 could also be shaped so asto function similarly to a curette and could be used to clean the earcanal prior to tube placement. The removable element 3649 could beshaped so as to accept and hold an absorbable element such as a piece ofopen cell foam or absorbent cloth, which could then be used to transporta medication down the ear canal.

The removable nature of the nose assembly from the ‘rack and pull’interface between the nose assembly and the handle assembly allow forfunction-specific nose assemblies other than the insertion type functionof the describe nose assembly 203 for inserting a ventilation tube. Forexample, a nose assembly that only applies topical analgesic ispossible. In such an embodiment, the cutting sheath could be replaced byan absorbent pad, and the actuation mechanism could trigger the releaseof an analgesic stored within the hollow positioning rod or anotherelement such that it is absorbed into the nose assembly for application.A nose assembly specialized for the creation of myringotomies onlywithout subsequent tube placement is another exemplary function-specificassembly. Such a nose assembly could comprise an element to incise theTM and an element to capture a sample of fluid for laboratory analysis.Upon the incision and capture of a sample, the entire nose assemblycould be removed from the handle and sent to a laboratory. A noseassembly for spraying or atomizing medication is another exemplaryfunction-specific assembly. Such a nose assembly could comprise adistribution element for dispersing the medicine located along or inplace of the positioning rod. Actuation at the handle would result inthe release and distribution of the medication. A viewing nose assemblyis still another exemplary function-specific assembly. The viewing noseassembly could comprise a positioning member with a flexible distalportion and a viewing member, such as a fiber optic scope. Actuation ofthe scroll wheel would move the flexible distal portion of the viewingmember, allowing a clinician to change the viewing zone inside the body.

A nose assembly for inserting ear wicks of various length is yet anotherexemplary function-specific assembly and could comprise all of thecomponents described for nose assembly 203, but also comprises anadjustable visualization element that lets the user adjust avisualization tab independent of the sheath. Because an ear wick may notinclude a visualization tab, a tab on the cutting sheath, or on asecondary sheath may be necessary. For example, FIG. 68 illustrates avisualization tab 688 on safety sheath 637. A visualization tab on asecondary sheath that is frictionally attached over a cutting sheathwould allow the user to manually adjust the depth of the visualizationtab, and would also allow the user to rotate the visualization tabaround the cutting sheath to for optimal placement and directvisualization. Such an adjustable secondary visualization tab could beused on any nose assembly where adjustability or enhanced depthvisualization is desired. Other function-specific removable assembliesthan those that are described are possible.

FIG. 94 illustrates a section view of insertion end 202 of insertionsystem 200 interfacing with a speculum-like device 3793. FIG. 84illustrates an enlarged view of FIG. 94. In this embodiment, safetysheath 637 serves to cover the joint between the cutting sheath 206 andthe positioning rod 204, ensuring that the proximal end of the safetysheath does not contact the front lip of the speculum 3793 during use,which could interfere with the retraction of cutting sheath 206 requiredfor ventilation tube deployment. An alternative embodiment uses acutting sheath with a tapered proximal end to minimize the potential forinterference with a speculum instead of a safety sheath. In theembodiment illustrated in FIGS. 94 and 95, safety sheath 637 may alsoprotect the distal end cutting edge 209 prior to and/or after deviceuse, but it may also just cover the joint between cutting sheath 206 andpositioning rod 204, and not need to be repositioned before and/or afterventilation tube deployment.

FIGS. 96-98 illustrate an embodiment of a speculum-like device 3893 withunique features for interfacing with an insertion system 200. FIG. 96 isa perspective view, FIG. 97 is a end view and FIG. 98 is a side view.FIGS. 96-98 illustrate speculum 3893 with a clear cover 3895 over thelarger opening. This clear cover 3895 has an opening 3896 that issmaller than the normal speculum opening 3897 through which theinsertion end 202 of insertion system 200 is passed. This smalleropening 3896 provides for a surface to rest the positioning rod 204against to improve stability during ventilation tube insertion.Alternatively or in addition to, a brace or rest 3898 may be included onthe inner surface of the speculum 3893 b, on the positioning rod (notillustrated), or on both.

Speculum 3893 may also include a passage and/or a clip for passage orattachment of one or more fiber-optic scopes or similar visualizationtools. While the insertion system can be used under direct visualizationor under magnification, such as that provided by an operating otoscopeor microscope, the use of fiber optic scopes could also be used. Theability to attach the fiber optic scope to a speculum like device allowsthe clinician to hold and position both devices with a single hand.These passages and attachments could also be used for passing orattaching tubes for the administration of drugs such as analgesics orantibiotics, or the passages themselves may act as a passage for drugs.

Although the subject matter has been described in language specific tostructural features and/or methodological acts, it is to be understoodthat the subject matter defined in the appended claims is notnecessarily limited to the specific features or acts described above.Rather, the specific features and acts described above are disclosed asexample forms of implementing the claim.

1-16. (canceled)
 17. A method of maintaining an opening in a membrane ofa body, the method comprising: advancing an insertion end of a noseassembly into the body so that a cutting edge of a cutting sheathpierces the membrane and a ventilation element is located across themembrane, the nose assembly including a positioning rod extending from anose of the nose assembly to the insertion end, the cutting sheathsurrounding a distal end of a positioning rod and an actuation memberextending from the nose to a distal end attached to the cutting sheath,wherein the ventilation element is loaded in the cutting sheath and islocated distal to the distal end of the positioning rod and proximal tothe insertion end; moving an actuating element located on a handleassembly that is coupled to the nose of the nose assembly from a firstposition to a second position to retract the cutting sheath from aroundthe ventilation element and along the positioning rod to thereby leavethe ventilation element across the membrane; and removing the insertionend from the body.
 18. The method of claim 17, wherein the handleassembly is coupled to the nose of the nose assembly by assembling thenose on the nose assembly to a nose interface on the handle assembly by:engaging a tab on the nose with a shelf portion in a recessed area ofthe nose interface; and moving the tab to engage with one of a pluralityof spaced apart detents located in a remaining portion of the recessedarea, thereby engaging the actuation member with the actuating element.19. (canceled)
 20. The method of claim 17, wherein moving the actuatingelement located on the handle assembly from the first position to thesecond position comprises moving the actuating element located on thehandle assembly from a forward position that is located closer to theinsertion end to a backward position that is located closer to aproximal end of the handle assembly.
 21. The method of claim 17, furthercomprising rotatably adjusting the nose of the nose assembly in aplurality of lockable positions relative to the handle assembly beforeadvancing the insertion end of the nose assembly into the body.
 22. Themethod of claim 17, wherein the handle assembly is coupled to the noseof the nose assembly by assembling the nose on the nose assembly to anose interface on the handle assembly and rotating the nose so that atleast one feature on the nose couples with a feature on the actuatingelement.
 23. The method of claim 17, wherein the ventilation element islocated inside the cutting sheath before advancing the insertion end ofthe nose assembly into the body.
 24. The method of claim 17, whereinadvancing the insertion end of the nose assembly into the body so thatthe cutting edge of the cutting sheath pierces the membrane and theventilation element is located across the membrane comprises using avisualization tab that protrudes from the ventilation element andthrough a slot in the cutting sheath to ensure that the ventilationelement is located across the membrane.
 25. A method of maintaining anopening in a membrane of the body, the method comprising: advancing acutting sheath having a cutting edge that surrounds a distal portion ofa positioning rod into the body so that the cutting edge pierces themembrane and a ventilation element located inside the cutting edge ispositioned across the membrane, wherein the distal portion of thepositioning rod includes a slot that extends entirely through athickness of a wall of the positioning rod and for a length along thepositioning rod and wherein the cutting sheath surrounds at least aportion of the slot of the positioning rod; moving a flexible actuationelement that extends inside the positioning rod, through the slot in thepositioning rod and has a distal end that is attached to the cuttingsheath to retract the cutting sheath from around the ventilation elementto thereby leave the ventilation element across the membrane; andremoving the cutting sheath from the body.
 26. The method of claim 25,wherein moving the flexible actuation element to retract the cuttingsheath from around the ventilation element to thereby leave theventilation element across the membrane comprises moving the flexibleactuation element with an actuation element on a handle assembly thatcouples to the flexible actuation member.
 27. The method of claim 26,wherein moving the actuation element on the handle assembly comprisesmoving the actuation element from a first position to a second position.28. The method of claim 26, wherein the cutting sheath, the positioningrod and the flexible actuation member are all components of a noseassembly that has a nose that couples to the handle assembly, whereinthe nose rotatably adjusts in a plurality of lockable positions relativeto the handle assembly before the cutting sheath is advanced into thebody.
 29. The method of claim 25, wherein where the flexible actuationmember attaches to the cutting sheath is located internal to the cuttingsheath.
 30. The method of claim 25, wherein advancing the cutting sheathinto the body so that the cutting edge pierces the membrane and theventilation element is located across the membrane comprises using avisualization tab that protrudes from the ventilation element andthrough a slot in the cutting sheath to ensure that the ventilationelement is located across the membrane.
 31. A method of maintaining anopening in a membrane of the body, the method comprising: advancing aninsertion end of a nose assembly into the body, wherein the noseassembly includes a nose, a pull, a positioning rod that extends fromthe nose to the insertion end, a cutting sheath that surrounds a distalend of the positioning rod and has a cutting edge, and an actuationmember that couples to the pull and extends from the pull and attachesto the cutting sheath; piercing the membrane of the body with thecutting edge of the cutting sheath so that a ventilation element that isloaded inside the cutting sheath and distal to a distal end of thepositioning rod is located across the membrane; and retracting thecutting sheath from around the ventilation element and along thepositioning rod by moving an actuating element located on a handleassembly and coupled to the pull from a first position to a secondposition.
 32. The method of claim 31, wherein the handle assembly isassembled to the nose on the nose assembly by: engaging a tab on thenose with a shelf portion in a recessed area of the nose interface; andmoving the tab to engage with one of a plurality of spaced apart detentslocated in a remaining portion of the recessed area, thereby engagingthe actuation member with the actuating element.
 33. The method of claim31, wherein the handle assembly is coupled to the nose of the noseassembly by assembling the nose on the nose assembly to a nose interfaceon the handle assembly and rotating the nose so that at least onefeature on the nose couples with a feature on the actuating element. 34.The method of claim 31, wherein moving the actuating element located onthe handle assembly from the first position to the second positioncomprises moving the actuating element located on the handle assemblyfrom a forward position that is located closer to the insertion end to abackward position that is located closer to a proximal end of the handleassembly.
 35. The method of claim 31, wherein the nose of the noseassembly rotatably adjusts in a plurality of lockable positions relativeto the handle assembly before advancing the insertion end of the noseassembly into the body.
 36. The method of claim 31, wherein theventilation element is located in the cutting sheath before advancingthe insertion end of the nose assembly into the body.
 37. The method ofclaim 31, wherein advancing the insertion end of the nose assembly intothe body so that the cutting edge of the cutting sheath pierces themembrane and the ventilation element is located across the membranecomprises using a visualization tab that protrudes from the ventilationelement and through a slot in the cutting sheath to ensure that theventilation element is located across the membrane.